Chronic Conditions Warehouse Virtual Research Data Center CODEBOOK: Medicare Fee-For-Service (FFS) Claims (version L) PDF Free Download

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Chronic Conditions Warehouse Virtual Research Data Center CODEBOOK: Medicare Fee-For-Service (FFS) Claims (version L) PDF Free Download

Chronic Conditions Warehouse Virtual Research Data Center CODEBOOK: Medicare Fee-For-Service (FFS) Claims (version L) PDF free Download. Think more deeply and widely.

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Your source for national CMS Medicare and Medicaid research data

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare Fee-For-Service (FFS)

Claims (version L)

AUGUST 2024 │ VERSION 1.12

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 i

Revision Log

Date

Changed by

Revisions

Version

August 2024

K. Schneider

Added values and adjusted value descriptions for

CLM_NEXT_GNRTN_ACO_IND_CD1-5, DEMO_ID_NUM,

LINE_OTHR_APLD_IND_CD1-7, REV_CNTR_PMT_MTHD_IND_CD, and

REV_CNTR_STUS_IND_CD. Adjusted two historical values for

CLM_VAL_CD. Added state values for the PRVDR_NUM and related

comment in PRVDR_STATE_CD. Inserted caution re:

NCH_PTNT_STUS_IND_CD

1.12

January 2024

K. Schneider

Added new fields and corresponding descriptions for

BLG_PRVDR_SPCLTY_CD1, BLG_PRVDR_SPCLTY_CD2,

BLG_PRVDR_SPCLTY_CD3, BLG_PRVDR_TXNMY_CD to carrier base

file; RNDRNG_PRVDR_SPCLTY_CD1, RNDRNG_PRVDR_SPCLTY_CD2,

RNDRNG_PRVDR_SPCLTY_CD3, RNDRNG_PRVDR_TXNMY_CD,

LINE_POINT_OF_PCKP_ZIP_CD, and LINE_DROP_OFF_ZIP_CD to

carrier line file. Added fields to additional files: CLM_ADMSN_DT to

HHA and Hospice; CLM_CLNCL_TRIL_NUM to IP, SNF, HHA, Hospice

and OP files; CLM_NEXT_GNRTN_ACO_IND_CD1–

CLM_NEXT_GNRTN_ACO_IND_CD5 to DME line file. Added new

values and descriptions for CLM_RLT_COND_CD, CLM_VAL_CD,

DEMO_ID_NUM, AT_PHYSN_SPCLTY_CD, OP_PHYSN_SPCLTY_CD,

OT_PHYSN_SPCLTY_CD, RFR_PHYSN_SPCLTY_CD,

RNDRNG_PHYSN_SPCLTY_CD, LINE_PLACE_OF_SRVC_CD,

CLM_NEXT_GNRTN_ACO_IND_CD1–

CLM_NEXT_GNRTN_ACO_IND_CD5, PRVDR_NUM, and

PRVDR_STATE_CD

1.11

August 2023

K. Schneider

Added comment re: small number of incorrect NCH_CLM_TYPE_CD

values. Added new values and descriptions for CLM_PRCR_RTRN_CD,

CLM_RLT_COND_CD, CLM_RLT_OCRNC_CD, CLM_SPAN_CD,

CLM_VAL_CD, DMERC_OXGN_INITL_DT_CD,

LINE_OTHR_APLD_IND_CD1-7, LINE_PLACE_OF_SRVC_CD, and

PRVDR_NUM. Updated web link for MedPAC Payment Basic series,

and web link for revenue center codes (REV_CNTR)

1.10

January 2023

K. Schneider

Added new fields and corresponding descriptions for:

CLM_ADJUST_GRP_CD, CLM_ADJUST_RSN_CD, CLM_OP_PPS_IND,

CLM_PRCR_VRSN_CD, DMERC_OXGN_EQUIP_INITL_DT,

DMERC_OXGN_INITL_DT_CD, DMERC_OXGN_EQUIP_PRVS_DT,

ESRD_TRTMT_CHS_IND_CD, LINE_ADJUST_GRP_CD,

LINE_ADJUST_RSN_CD, LINE_RA_RMRK_CD,

MS_DRG_GRPR_VRSN_CD, OWNG_PRVDR_TIN_NUM,

PRVDR_FULL_CCN_NUM, REV_CNTR_ADJUST_GRP_CD,

REV_CNTR_ADJUST_RSN_CD, REV_CNTR_RA_RMRK_CD,

REV_CNTR_CRA_TPNIES_AMT, REV_CNTR_THRPY_RDCTN_AMT.

Added values and corresponding descriptions for

CARR_NUM, CLM_FREQ_CD, CLM_SRC_IP_ADMSN_CD, FI_NUM,

REV_CNTR

1.9

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 ii

Date

Changed by

Revisions

Version

April 2022

K. Schneider

A. Sisco

A. Meyer

Added values and corresponding descriptions for

AT_PHYSN_SPCLTY_CD, OP_PHYSN_SPCLTY_CD,

OT_PHYSN_SPCLTY_CD, RFR_PHYSN_SPCLTY_CD,

RNDRNG_PHYSN_SPCLTY_CD, CLM_NEXT_GNRTN_ACO_IND_CD1-

CLM_NEXT_GNRTN_ACO_IND_CD5, CLM_RLT_COND_CD,

CLM_SRVC_CLSFCTN_TYPE_CD, DEMO_ID_NUM,

LINE_OTHR_APLD_IND_CD1- LINE_OTHR_APLD_IND_CD7, REV_CNTR.

Adjusted historical values and formatting for CARR_NUM and

FI_NUM. Corrected values for CLM_VAL_CD, BENE_STATE_CD,

DMERC_LINE_PRCNG_STATE_CD, and PRVDR_STATE_CD. Updated

description for NCH_BENE_DSCHRG_DT and PRVDR_NUM.

1.8

February 2021

K. Schneider

K. Russell

C. Alleman

Migrated codebook to 2020 document template. Added four fields

due to NCH version L updates:

1. LTCH_DSCHRG_PYMT_ADJSTMT_AMT to IP Base Claim;

2. ORDRG_PHYSN_NPI to hospice, HH and OP revenue lines;

3. RC_VLNTRY_SRVC_IND_CD to hospice, HH and OP revenue lines;

4. LINE_VLNTRY_SRVC_IND_CD to carrier and DME lines.

Also changed CLM_DRG_CD from three to four characters, and

LINE_OTHR_APLD_IND_CD1-LINE_OTHR_APLD_IND_CD7 from one to

two characters

1.7

April 2020

S. Pietzsch

Added two fields to Part A layouts:

CLM_MODEL_REIMBRSMT_AMT

RC_MODEL_REIMBRSMT_AMT

1.6

September 2019

K. Schneider

Added values and corresponding descriptions for

CLM_VAL_CD

LINE_OTHR_APLD_IND_CD1–7,

and provider specialty code

(AT_PHYSN_SPCLTY_CD, OP_PHYSN_SPCLTY_CD,

OT_PHYSN_SPCLTY_CD, RNDRNG_PHYSN_SPCLTY_CD, and

RFR_PHYSN_SPCLTY_CD)

1.5

May 2019

C. Alleman

K. Schneider

Added new fields: 1) CLM_RSDL_PYMT_IND_CD to all base claims, and

LINE_RSDL_PYMT_IND_CD to carrier and DME lines; 2)

CLM_RP_IND_CD to IP base claim, REV_CNTR_RP_IND_CD to SNF, HH,

hospice and OP revenue lines, and LINE_RP_IND_CD to carrier and

DME lines; 3) PRVDR_VLDTN_TYPE_CD to all base claims except for

DME, and LINE_PRVDR_VLDTN_TYPE_CD to carrier and DME line; 4)

RR_BRD_EXCLSN_IND_SW to IP,SNF, HH, hospice and OP base claims,

and LINE_RR_BRD_EXCLSN_IND_SW to DME line; 5)

CLM_IP_INITL_MS_DRG_CD to IP base file; and 6)

DMERC_LINE_FRGN_ADR_IND to DME line.

Also changed the name of the HHA base field FINL_STD_AMT to be

PPS_STD_VAL_PYMT_AMT; edited description of FINL_STD_AMT and

PPS_STD_VAL_PYMT_AMT.

1.4

January 2019

C. Alleman

K. Schneider

Added new valid value for CLM_RLT_OCRNC_CD and new values for

LINE_OTHR_APLD_IND_CD

1.3

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 iii

Date

Changed by

Revisions

Version

August 2018

C. Alleman

K. Schneider

Updated comments for variables: AT_PHYSN_SPCLTY_CD,

CARR_LINE_ANSTHSA_UNIT_CNT, LINE_SRVC_CNT, TAX_NUM.

Updated variable lengths: CARR_LINE_ANSTHSA_UNIT_CNT,

LINE_SRVC_CNT.

Updated values for LINE_PLACE_OF_SRVC_CD (values 02,18,19).

1.2

April 2018

C. Alleman

Updated TOC to sort on Long Name instead of Short Name.

1.1

February 2018

C. Alleman

K. Schneider

Initial release of Codebook for Medicare Fee-For-Service Claims,

Version K with CR13 updates.

1.0

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 iv

Tips on Navigating the Codebook

This document is a detailed codebook that describes each variable in the Medicare fee-for-service (FFS) claims

research files. We have included several ways for users to quickly find the information they need:

• A complete listing of all files’ variables, in alphabetical order based on their SAS variable names.

• Individual entries for each variable contain a short description of the variable, the possible values for the variable,

and, in many cases, comments discussing the variable construction and use.

We have included hyperlinks throughout the codebook to make it easier for users to navigate between the table of

contents and the detailed entries for the individual variables:

• Clicking on any variable name in the Table of Contents will take you to the detailed description for that variable.

• From the individual variable page, clicking on the ^Back to TOC^ link after each variable description will take you

back to the Table of Contents.

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 v

Table of Contents

This section of the codebook contains a list of all variables in alphabetical order based on the SAS variable name.

Quick links:

Variable Details............................................................................................................................................................. 1

ACO_ID_NUM ........................................................................................................................................................... 1

ADMTG_DGNS_CD .................................................................................................................................................... 2

ADMTG_DGNS_VRSN_CD ......................................................................................................................................... 3

AT_PHYSN_NPI ......................................................................................................................................................... 4

AT_PHYSN_SPCLTY_CD ............................................................................................................................................. 5

AT_PHYSN_UPIN ....................................................................................................................................................... 8

BENE_CNTY_CD ........................................................................................................................................................ 9

BENE_HOSPC_PRD_CNT ......................................................................................................................................... 10

BENE_ID ................................................................................................................................................................. 11

BENE_LRD_USED_CNT ............................................................................................................................................ 12

BENE_MLG_CNTCT_ZIP_CD .................................................................................................................................... 13

BENE_RACE_CD ...................................................................................................................................................... 14

BENE_STATE_CD ..................................................................................................................................................... 15

BENE_TOT_COINSRNC_DAYS_CNT .......................................................................................................................... 17

BETOS_CD............................................................................................................................................................... 18

BLG_PRVDR_SPCLTY_CD1 ....................................................................................................................................... 20

BLG_PRVDR_SPCLTY_CD2 ....................................................................................................................................... 20

BLG_PRVDR_SPCLTY_CD3 ....................................................................................................................................... 20

BLG_PRVDR_TXNMY_CD ......................................................................................................................................... 23

CARR_CLM_BLG_NPI_NUM .................................................................................................................................... 24

CARR_CLM_CASH_DDCTBL_APLD_AMT .................................................................................................................. 25

CARR_CLM_ENTRY_CD ........................................................................................................................................... 26

CARR_CLM_HCPCS_YR_CD ..................................................................................................................................... 27

CARR_CLM_PMT_DNL_CD ...................................................................................................................................... 28

CARR_CLM_PRVDR_ASGNMT_IND_SW................................................................................................................... 31

CARR_CLM_RFRNG_PIN_NUM ................................................................................................................................ 32

CARR_CLM_SOS_NPI_NUM .................................................................................................................................... 33

CARR_LINE_ANSTHSA_UNIT_CNT ........................................................................................................................... 34

CARR_LINE_CL_CHRG_AMT .................................................................................................................................... 35

CARR_LINE_CLIA_LAB_NUM ................................................................................................................................... 36

CARR_LINE_MDPP_NPI_NUM ................................................................................................................................. 37

CARR_LINE_MTUS_CD ............................................................................................................................................ 38

CARR_LINE_MTUS_CNT .......................................................................................................................................... 39

CARR_LINE_PRCNG_LCLTY_CD ................................................................................................................................ 40

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 vi

CARR_LINE_PRVDR_TYPE_CD ................................................................................................................................. 42

CARR_LINE_RDCD_PMT_PHYS_ASTN_C .................................................................................................................. 43

CARR_LINE_RX_NUM .............................................................................................................................................. 44

CARR_NUM ............................................................................................................................................................ 45

CARR_PRFRNG_PIN_NUM ...................................................................................................................................... 50

CLAIM_QUERY_CODE ............................................................................................................................................. 51

CLM_ADJUST_GRP_CD............................................................................................................................................ 52

CLM_ADJUST_RSN_CD ............................................................................................................................................ 53

CLM_ADMSN_DT .................................................................................................................................................... 54

CLM_BASE_OPRTG_DRG_AMT ............................................................................................................................... 55

CLM_BENE_ID_TYPE_CD ......................................................................................................................................... 56

CLM_BENE_PD_AMT .............................................................................................................................................. 57

CLM_BNDLD_ADJSTMT_PMT_AMT......................................................................................................................... 58

CLM_BNDLD_MODEL_1_DSCNT_PCT ...................................................................................................................... 59

CLM_CARE_IMPRVMT_MODEL_CD1 ....................................................................................................................... 60

CLM_CARE_IMPRVMT_MODEL_CD2 ....................................................................................................................... 60

CLM_CARE_IMPRVMT_MODEL_CD3 ....................................................................................................................... 60

CLM_CARE_IMPRVMT_MODEL_CD4 ....................................................................................................................... 60

CLM_CLNCL_TRIL_NUM .......................................................................................................................................... 61

CLM_DISP_CD ......................................................................................................................................................... 62

CLM_DRG_CD ......................................................................................................................................................... 63

CLM_DRG_OUTLIER_STAY_CD ................................................................................................................................ 64

CLM_E_POA_IND_SW1 ........................................................................................................................................... 65

CLM_E_POA_IND_SW2 ........................................................................................................................................... 65

CLM_E_POA_IND_SW3 ........................................................................................................................................... 65

CLM_E_POA_IND_SW4 ........................................................................................................................................... 65

CLM_E_POA_IND_SW5 ........................................................................................................................................... 65

CLM_E_POA_IND_SW6 ........................................................................................................................................... 65

CLM_E_POA_IND_SW7 ........................................................................................................................................... 65

CLM_E_POA_IND_SW8 ........................................................................................................................................... 65

CLM_E_POA_IND_SW9 ........................................................................................................................................... 65

CLM_E_POA_IND_SW10 ......................................................................................................................................... 65

CLM_E_POA_IND_SW11 ......................................................................................................................................... 65

CLM_E_POA_IND_SW12 ......................................................................................................................................... 65

CLM_FAC_TYPE_CD ................................................................................................................................................ 67

CLM_FREQ_CD........................................................................................................................................................ 68

CLM_FROM_DT ...................................................................................................................................................... 69

CLM_FULL_STD_PYMT_AMT ................................................................................................................................... 70

CLM_HHA_LUPA_IND_CD ....................................................................................................................................... 71

CLM_HHA_RFRL_CD ............................................................................................................................................... 72

CLM_HHA_TOT_VISIT_CNT ..................................................................................................................................... 74

CLM_HOSPC_START_DT_ID .................................................................................................................................... 75

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 vii

CLM_HRR_ADJSTMT_PCT ....................................................................................................................................... 76

CLM_HRR_ADJSTMT_PMT_AMT ............................................................................................................................. 77

CLM_HRR_PRTCPNT_IND_CD ................................................................................................................................. 78

CLM_ID .................................................................................................................................................................. 79

CLM_IP_ADMSN_TYPE_CD ..................................................................................................................................... 80

CLM_IP_INITL_MS_DRG_CD ................................................................................................................................... 81

CLM_IP_LOW_VOL_PMT_AMT ............................................................................................................................... 82

CLM_LINE_NUM ..................................................................................................................................................... 83

CLM_MCO_PD_SW ................................................................................................................................................. 84

CLM_MDCL_REC ..................................................................................................................................................... 85

CLM_MDCR_NON_PMT_RSN_CD ........................................................................................................................... 86

CLM_MODEL_4_READMSN_IND_CD ....................................................................................................................... 89

CLM_MODEL_REIMBRSMT_AMT ............................................................................................................................ 90

CLM_NEXT_GNRTN_ACO_IND_CD1 ........................................................................................................................ 91

CLM_NEXT_GNRTN_ACO_IND_CD2 ........................................................................................................................ 91

CLM_NEXT_GNRTN_ACO_IND_CD3 ........................................................................................................................ 91

CLM_NEXT_GNRTN_ACO_IND_CD4 ........................................................................................................................ 91

CLM_NEXT_GNRTN_ACO_IND_CD5 ........................................................................................................................ 91

CLM_NON_UTLZTN_DAYS_CNT .............................................................................................................................. 93

CLM_OP_BENE_PMT_AMT ..................................................................................................................................... 94

CLM_OP_ESRD_MTHD_CD...................................................................................................................................... 95

CLM_OP_PPS_IND .................................................................................................................................................. 96

CLM_OP_PRVDR_PMT_AMT ................................................................................................................................... 97

CLM_OP_TRANS_TYPE_CD...................................................................................................................................... 98

CLM_PASS_THRU_PER_DIEM_AMT ........................................................................................................................ 99

CLM_PMT_AMT .................................................................................................................................................... 100

CLM_POA_IND_SW1 ............................................................................................................................................. 101

CLM_POA_IND_SW2 ............................................................................................................................................. 101

CLM_POA_IND_SW3 ............................................................................................................................................. 101

CLM_POA_IND_SW4 ............................................................................................................................................. 101

CLM_POA_IND_SW5 ............................................................................................................................................. 101

CLM_POA_IND_SW6 ............................................................................................................................................. 101

CLM_POA_IND_SW7 ............................................................................................................................................. 101

CLM_POA_IND_SW8 ............................................................................................................................................. 101

CLM_POA_IND_SW9 ............................................................................................................................................. 101

CLM_POA_IND_SW10 ........................................................................................................................................... 101

CLM_POA_IND_SW11 ........................................................................................................................................... 101

CLM_POA_IND_SW12 ........................................................................................................................................... 101

CLM_POA_IND_SW13 ........................................................................................................................................... 101

CLM_POA_IND_SW14 ........................................................................................................................................... 101

CLM_POA_IND_SW15 ........................................................................................................................................... 101

CLM_POA_IND_SW16 ........................................................................................................................................... 101

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 viii

CLM_POA_IND_SW17 ........................................................................................................................................... 101

CLM_POA_IND_SW18 ........................................................................................................................................... 101

CLM_POA_IND_SW19 ........................................................................................................................................... 101

CLM_POA_IND_SW20 ........................................................................................................................................... 101

CLM_POA_IND_SW21 ........................................................................................................................................... 101

CLM_POA_IND_SW22 ........................................................................................................................................... 101

CLM_POA_IND_SW23 ........................................................................................................................................... 101

CLM_POA_IND_SW24 ........................................................................................................................................... 101

CLM_POA_IND_SW25 ........................................................................................................................................... 101

CLM_PPS_CPTL_DRG_WT_NUM ........................................................................................................................... 103

CLM_PPS_CPTL_DSPRPRTNT_SHR_AMT ............................................................................................................... 104

CLM_PPS_CPTL_EXCPTN_AMT .............................................................................................................................. 105

CLM_PPS_CPTL_FSP_AMT .................................................................................................................................... 106

CLM_PPS_CPTL_IME_AMT .................................................................................................................................... 107

CLM_PPS_CPTL_OUTLIER_AMT............................................................................................................................. 108

CLM_PPS_IND_CD ................................................................................................................................................ 109

CLM_PPS_OLD_CPTL_HLD_HRMLS_AMT .............................................................................................................. 110

CLM_PRCR_RTRN_CD ........................................................................................................................................... 111

CLM_PRCR_VRSN_CD ........................................................................................................................................... 119

CLM_RLT_COND_CD ............................................................................................................................................. 120

CLM_RLT_OCRNC_CD ........................................................................................................................................... 130

CLM_RLT_OCRNC_DT ........................................................................................................................................... 134

CLM_RP_IND_CD .................................................................................................................................................. 135

CLM_RSDL_PYMT_IND_CD ................................................................................................................................... 136

CLM_SITE_NTRL_PYMT_CST_AMT ........................................................................................................................ 137

CLM_SITE_NTRL_PYMT_IPPS_AMT ....................................................................................................................... 138

CLM_SPAN_CD ..................................................................................................................................................... 139

CLM_SPAN_FROM_DT .......................................................................................................................................... 141

CLM_SPAN_THRU_DT ........................................................................................................................................... 142

CLM_SRC_IP_ADMSN_CD ..................................................................................................................................... 143

CLM_SRVC_CLSFCTN_TYPE_CD ............................................................................................................................. 145

CLM_SRVC_FAC_ZIP_CD ....................................................................................................................................... 146

CLM_SS_OUTLIER_STD_PYMT_AMT ..................................................................................................................... 147

CLM_THRU_DT ..................................................................................................................................................... 148

CLM_TOT_CHRG_AMT .......................................................................................................................................... 149

CLM_TOT_PPS_CPTL_AMT .................................................................................................................................... 150

CLM_TRTMT_AUTHRZTN_NUM ............................................................................................................................ 151

CLM_UNCOMPD_CARE_PMT_AMT ....................................................................................................................... 152

CLM_UTLZTN_DAY_CNT ....................................................................................................................................... 153

CLM_VAL_AMT ..................................................................................................................................................... 154

CLM_VAL_CD ........................................................................................................................................................ 155

CLM_VBP_ADJSTMT_PCT ...................................................................................................................................... 167

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 ix

CLM_VBP_ADJSTMT_PMT_AMT ........................................................................................................................... 168

CLM_VBP_PRTCPNT_IND_CD ................................................................................................................................ 169

CPO_ORG_NPI_NUM ............................................................................................................................................ 170

CPO_PRVDR_NUM ................................................................................................................................................ 171

DEMO_ID_NUM.................................................................................................................................................... 172

DEMO_ID_SQNC_NUM ......................................................................................................................................... 175

DEMO_INFO_TXT .................................................................................................................................................. 176

DMERC_LINE_FRGN_ADR_IND .............................................................................................................................. 177

DMERC_LINE_MTUS_CD ....................................................................................................................................... 178

DMERC_LINE_MTUS_CNT ..................................................................................................................................... 179

DMERC_LINE_PRCNG_STATE_CD .......................................................................................................................... 180

DMERC_LINE_SCRN_SVGS_AMT ........................................................................................................................... 182

DMERC_LINE_SUPPLR_TYPE_CD ........................................................................................................................... 183

DMERC_OXGN_EQUIP_INITL_DT .......................................................................................................................... 184

DMERC_OXGN_EQUIP_PRVS_DT .......................................................................................................................... 185

DMERC_OXGN_INITL_DT_CD ................................................................................................................................ 186

DOB_DT ................................................................................................................................................................ 187

DSH_OP_CLM_VAL_AMT ...................................................................................................................................... 188

EHR_PGM_RDCTN_IND_SW .................................................................................................................................. 189

EHR_PYMT_ADJSTMT_AMT .................................................................................................................................. 190

ESRD_TRTMT_CHS_IND_CD .................................................................................................................................. 191

FI_CLM_ACTN_CD ................................................................................................................................................. 192

FI_CLM_PROC_DT ................................................................................................................................................. 193

FI_NUM ................................................................................................................................................................ 194

FINL_STD_AMT ..................................................................................................................................................... 198

FST_DGNS_E_CD................................................................................................................................................... 199

FST_DGNS_E_VRSN_CD ........................................................................................................................................ 200

GNDR_CD ............................................................................................................................................................. 201

HAC_PGM_RDCTN_IND_SW ................................................................................................................................. 202

HCPCS_1ST_MDFR_CD .......................................................................................................................................... 203

HCPCS_2ND_MDFR_CD ........................................................................................................................................ 204

HCPCS_3RD_MDFR_CD ......................................................................................................................................... 205

HCPCS_4TH_MDFR_CD ......................................................................................................................................... 206

HCPCS_CD ............................................................................................................................................................ 207

HPSA_SCRCTY_IND_CD ......................................................................................................................................... 209

ICD_DGNS_CD1 .................................................................................................................................................... 210

ICD_DGNS_CD2 .................................................................................................................................................... 210

ICD_DGNS_CD3 .................................................................................................................................................... 210

ICD_DGNS_CD4 .................................................................................................................................................... 210

ICD_DGNS_CD5 .................................................................................................................................................... 210

ICD_DGNS_CD6 .................................................................................................................................................... 210

ICD_DGNS_CD7 .................................................................................................................................................... 210

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 x

ICD_DGNS_CD8 .................................................................................................................................................... 210

ICD_DGNS_CD9 .................................................................................................................................................... 210

ICD_DGNS_CD10 .................................................................................................................................................. 210

ICD_DGNS_CD11 .................................................................................................................................................. 210

ICD_DGNS_CD12 .................................................................................................................................................. 210

ICD_DGNS_CD13 .................................................................................................................................................. 210

ICD_DGNS_CD14 .................................................................................................................................................. 210

ICD_DGNS_CD15 .................................................................................................................................................. 210

ICD_DGNS_CD16 .................................................................................................................................................. 210

ICD_DGNS_CD17 .................................................................................................................................................. 210

ICD_DGNS_CD18 .................................................................................................................................................. 210

ICD_DGNS_CD19 .................................................................................................................................................. 210

ICD_DGNS_CD20 .................................................................................................................................................. 210

ICD_DGNS_CD21 .................................................................................................................................................. 210

ICD_DGNS_CD22 .................................................................................................................................................. 210

ICD_DGNS_CD23 .................................................................................................................................................. 210

ICD_DGNS_CD24 .................................................................................................................................................. 210

ICD_DGNS_CD25 .................................................................................................................................................. 210

ICD_DGNS_E_CD1 ................................................................................................................................................. 212

ICD_DGNS_E_CD2 ................................................................................................................................................. 212

ICD_DGNS_E_CD3 ................................................................................................................................................. 212

ICD_DGNS_E_CD4 ................................................................................................................................................. 212

ICD_DGNS_E_CD5 ................................................................................................................................................. 212

ICD_DGNS_E_CD6 ................................................................................................................................................. 212

ICD_DGNS_E_CD7 ................................................................................................................................................. 212

ICD_DGNS_E_CD8 ................................................................................................................................................. 212

ICD_DGNS_E_CD9 ................................................................................................................................................. 212

ICD_DGNS_E_CD10 ............................................................................................................................................... 212

ICD_DGNS_E_CD11 ............................................................................................................................................... 212

ICD_DGNS_E_CD12 ............................................................................................................................................... 212

ICD_DGNS_VRSN_CD1 .......................................................................................................................................... 213

ICD_DGNS_VRSN_CD2 .......................................................................................................................................... 213

ICD_DGNS_VRSN_CD3 .......................................................................................................................................... 213

ICD_DGNS_VRSN_CD4 .......................................................................................................................................... 213

ICD_DGNS_VRSN_CD5 .......................................................................................................................................... 213

ICD_DGNS_VRSN_CD6 .......................................................................................................................................... 213

ICD_DGNS_VRSN_CD7 .......................................................................................................................................... 213

ICD_DGNS_VRSN_CD8 .......................................................................................................................................... 213

ICD_DGNS_VRSN_CD9 .......................................................................................................................................... 213

ICD_DGNS_VRSN_CD10 ........................................................................................................................................ 213

ICD_DGNS_VRSN_CD11 ........................................................................................................................................ 213

ICD_DGNS_VRSN_CD12 ........................................................................................................................................ 213

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ICD_DGNS_VRSN_CD13 ........................................................................................................................................ 213

ICD_DGNS_VRSN_CD14 ........................................................................................................................................ 213

ICD_DGNS_VRSN_CD15 ........................................................................................................................................ 213

ICD_DGNS_VRSN_CD16 ........................................................................................................................................ 213

ICD_DGNS_VRSN_CD17 ........................................................................................................................................ 213

ICD_DGNS_VRSN_CD18 ........................................................................................................................................ 213

ICD_DGNS_VRSN_CD19 ........................................................................................................................................ 213

ICD_DGNS_VRSN_CD20 ........................................................................................................................................ 213

ICD_DGNS_VRSN_CD21 ........................................................................................................................................ 213

ICD_DGNS_VRSN_CD22 ........................................................................................................................................ 213

ICD_DGNS_VRSN_CD23 ........................................................................................................................................ 213

ICD_DGNS_VRSN_CD24 ........................................................................................................................................ 213

ICD_DGNS_VRSN_CD25 ........................................................................................................................................ 213

ICD_PRCDR_CD1 ................................................................................................................................................... 215

ICD_PRCDR_CD2 ................................................................................................................................................... 215

ICD_PRCDR_CD3 ................................................................................................................................................... 215

ICD_PRCDR_CD4 ................................................................................................................................................... 215

ICD_PRCDR_CD5 ................................................................................................................................................... 215

ICD_PRCDR_CD6 ................................................................................................................................................... 215

ICD_PRCDR_CD7 ................................................................................................................................................... 215

ICD_PRCDR_CD8 ................................................................................................................................................... 215

ICD_PRCDR_CD9 ................................................................................................................................................... 215

ICD_PRCDR_CD10 ................................................................................................................................................. 215

ICD_PRCDR_CD11 ................................................................................................................................................. 215

ICD_PRCDR_CD12 ................................................................................................................................................. 215

ICD_PRCDR_CD13 ................................................................................................................................................. 215

ICD_PRCDR_CD14 ................................................................................................................................................. 215

ICD_PRCDR_CD15 ................................................................................................................................................. 215

ICD_PRCDR_CD16 ................................................................................................................................................. 215

ICD_PRCDR_CD17 ................................................................................................................................................. 215

ICD_PRCDR_CD18 ................................................................................................................................................. 215

ICD_PRCDR_CD19 ................................................................................................................................................. 215

ICD_PRCDR_CD20 ................................................................................................................................................. 215

ICD_PRCDR_CD21 ................................................................................................................................................. 215

ICD_PRCDR_CD22 ................................................................................................................................................. 215

ICD_PRCDR_CD23 ................................................................................................................................................. 215

ICD_PRCDR_CD24 ................................................................................................................................................. 215

ICD_PRCDR_CD25 ................................................................................................................................................. 215

ICD_PRCDR_VRSN_CD1......................................................................................................................................... 217

ICD_PRCDR_VRSN_CD2......................................................................................................................................... 217

ICD_PRCDR_VRSN_CD3......................................................................................................................................... 217

ICD_PRCDR_VRSN_CD4......................................................................................................................................... 217

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ICD_PRCDR_VRSN_CD5......................................................................................................................................... 217

ICD_PRCDR_VRSN_CD6......................................................................................................................................... 217

ICD_PRCDR_VRSN_CD7......................................................................................................................................... 217

ICD_PRCDR_VRSN_CD8......................................................................................................................................... 217

ICD_PRCDR_VRSN_CD9......................................................................................................................................... 217

ICD_PRCDR_VRSN_CD10 ....................................................................................................................................... 217

ICD_PRCDR_VRSN_CD11 ....................................................................................................................................... 217

ICD_PRCDR_VRSN_CD12 ....................................................................................................................................... 217

ICD_PRCDR_VRSN_CD13 ....................................................................................................................................... 217

ICD_PRCDR_VRSN_CD14 ....................................................................................................................................... 217

ICD_PRCDR_VRSN_CD15 ....................................................................................................................................... 217

ICD_PRCDR_VRSN_CD16 ....................................................................................................................................... 217

ICD_PRCDR_VRSN_CD17 ....................................................................................................................................... 217

ICD_PRCDR_VRSN_CD18 ....................................................................................................................................... 217

ICD_PRCDR_VRSN_CD19 ....................................................................................................................................... 217

ICD_PRCDR_VRSN_CD20 ....................................................................................................................................... 217

ICD_PRCDR_VRSN_CD21 ....................................................................................................................................... 217

ICD_PRCDR_VRSN_CD22 ....................................................................................................................................... 217

ICD_PRCDR_VRSN_CD23 ....................................................................................................................................... 217

ICD_PRCDR_VRSN_CD24 ....................................................................................................................................... 217

ICD_PRCDR_VRSN_CD25 ....................................................................................................................................... 217

IME_OP_CLM_VAL_AMT ...................................................................................................................................... 219

LINE_1ST_EXPNS_DT ............................................................................................................................................ 220

LINE_ADJUST_GRP_CD .......................................................................................................................................... 221

LINE_ADJUST_RSN_CD .......................................................................................................................................... 222

LINE_ALOWD_CHRG_AMT .................................................................................................................................... 223

LINE_BENE_PMT_AMT.......................................................................................................................................... 224

LINE_BENE_PRMRY_PYR_CD................................................................................................................................. 225

LINE_BENE_PRMRY_PYR_PD_AMT ....................................................................................................................... 226

LINE_BENE_PTB_DDCTBL_AMT............................................................................................................................. 227

LINE_CMS_TYPE_SRVC_CD ................................................................................................................................... 228

LINE_COINSRNC_AMT........................................................................................................................................... 229

LINE_DME_PRCHS_PRICE_AMT ............................................................................................................................ 230

LINE_DROP_OFF_ZIP_CD ...................................................................................................................................... 231

LINE_HCT_HGB_RSLT_NUM .................................................................................................................................. 232

LINE_HCT_HGB_TYPE_CD ..................................................................................................................................... 233

LINE_ICD_DGNS_CD.............................................................................................................................................. 234

LINE_ICD_DGNS_VRSN_CD ................................................................................................................................... 235

LINE_LAST_EXPNS_DT ........................................................................................................................................... 236

LINE_NCH_PMT_AMT ........................................................................................................................................... 237

LINE_NDC_CD ....................................................................................................................................................... 238

LINE_NUM ............................................................................................................................................................ 239

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LINE_OTHR_APLD_AMT1 ...................................................................................................................................... 240

LINE_OTHR_APLD_AMT2 ...................................................................................................................................... 240

LINE_OTHR_APLD_AMT3 ...................................................................................................................................... 240

LINE_OTHR_APLD_AMT4 ...................................................................................................................................... 240

LINE_OTHR_APLD_AMT5 ...................................................................................................................................... 240

LINE_OTHR_APLD_AMT6 ...................................................................................................................................... 240

LINE_OTHR_APLD_AMT7 ...................................................................................................................................... 240

LINE_OTHR_APLD_IND_CD1 ................................................................................................................................. 241

LINE_OTHR_APLD_IND_CD2 ................................................................................................................................. 241

LINE_OTHR_APLD_IND_CD3 ................................................................................................................................. 241

LINE_OTHR_APLD_IND_CD4 ................................................................................................................................. 241

LINE_OTHR_APLD_IND_CD5 ................................................................................................................................. 241

LINE_OTHR_APLD_IND_CD6 ................................................................................................................................. 241

LINE_OTHR_APLD_IND_CD7 ................................................................................................................................. 241

LINE_PICK_UP_ZIP_CD .......................................................................................................................................... 243

LINE_PLACE_OF_SRVC_CD .................................................................................................................................... 244

LINE_PMT_80_100_CD ......................................................................................................................................... 248

LINE_PRCSG_IND_CD ............................................................................................................................................ 249

LINE_PRMRY_ALOWD_CHRG_AMT ....................................................................................................................... 251

LINE_PRVDR_PMT_AMT ....................................................................................................................................... 252

LINE_PRVDR_VLDTN_TYPE_CD ............................................................................................................................. 253

LINE_RA_RMRK_CD .............................................................................................................................................. 254

LINE_RP_IND_CD .................................................................................................................................................. 255

LINE_RR_BRD_EXCLSN_IND_SW ........................................................................................................................... 256

LINE_RSDL_PYMT_IND_CD ................................................................................................................................... 257

LINE_SBMTD_CHRG_AMT ..................................................................................................................................... 258

LINE_SERVICE_DEDUCTIBLE .................................................................................................................................. 259

LINE_SRVC_CNT .................................................................................................................................................... 260

LINE_VLNTRY_SRVC_IND_CD ................................................................................................................................ 261

LTCH_DSCHRG_PYMT_ADJSTMT_AMT.................................................................................................................. 262

MS_DRG_GRPR_VRSN_CD .................................................................................................................................... 263

NCH_ACTV_OR_CVRD_LVL_CARE_THRU ............................................................................................................... 264

NCH_BENE_BLOOD_DDCTBL_LBLTY_AM .............................................................................................................. 265

NCH_BENE_DSCHRG_DT ....................................................................................................................................... 266

NCH_BENE_IP_DDCTBL_AMT................................................................................................................................ 267

NCH_BENE_MDCR_BNFTS_EXHTD_DT_I ............................................................................................................... 268

NCH_BENE_PTA_COINSRNC_LBLTY_AM ............................................................................................................... 269

NCH_BENE_PTB_COINSRNC_AMT......................................................................................................................... 270

NCH_BENE_PTB_DDCTBL_AMT ............................................................................................................................. 271

NCH_BLOOD_PNTS_FRNSHD_QTY ........................................................................................................................ 272

NCH_CARR_CLM_ALOWD_AMT ............................................................................................................................ 273

NCH_CARR_CLM_SBMTD_CHRG_AMT .................................................................................................................. 274

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NCH_CLM_BENE_PMT_AMT ................................................................................................................................. 275

NCH_CLM_PRVDR_PMT_AMT .............................................................................................................................. 276

NCH_CLM_TYPE_CD ............................................................................................................................................. 277

NCH_DRG_OUTLIER_APRVD_PMT_AMT ............................................................................................................... 278

NCH_IP_NCVRD_CHRG_AMT ................................................................................................................................ 279

NCH_IP_TOT_DDCTN_AMT ................................................................................................................................... 280

NCH_NEAR_LINE_REC_IDENT_CD ......................................................................................................................... 281

NCH_PRMRY_PYR_CLM_PD_AMT ......................................................................................................................... 282

NCH_PRMRY_PYR_CD ........................................................................................................................................... 283

NCH_PROFNL_CMPNT_CHRG_AMT ...................................................................................................................... 284

NCH_PTNT_STUS_IND_CD .................................................................................................................................... 285

NCH_QLFYD_STAY_FROM_DT ............................................................................................................................... 286

NCH_QLFYD_STAY_THRU_DT ................................................................................................................................ 287

NCH_VRFD_NCVRD_STAY_FROM_DT.................................................................................................................... 288

NCH_VRFD_NCVRD_STAY_THRU_DT .................................................................................................................... 289

NCH_WKLY_PROC_DT ........................................................................................................................................... 290

OP_PHYSN_NPI ..................................................................................................................................................... 291

OP_PHYSN_SPCLTY_CD ......................................................................................................................................... 292

OP_PHYSN_UPIN .................................................................................................................................................. 295

ORDRG_PHYSN_NPI .............................................................................................................................................. 296

ORG_NPI_NUM .................................................................................................................................................... 297

OT_PHYSN_NPI ..................................................................................................................................................... 298

OT_PHYSN_SPCLTY_CD ......................................................................................................................................... 299

OT_PHYSN_UPIN .................................................................................................................................................. 302

OWNG_PRVDR_TIN_NUM .................................................................................................................................... 303

PHYSN_ZIP_CD...................................................................................................................................................... 304

PPS_STD_VAL_PYMT_AMT ................................................................................................................................... 305

PRCDR_DT1 .......................................................................................................................................................... 306

PRCDR_DT2 .......................................................................................................................................................... 306

PRCDR_DT3 .......................................................................................................................................................... 306

PRCDR_DT4 .......................................................................................................................................................... 306

PRCDR_DT5 .......................................................................................................................................................... 306

PRCDR_DT6 .......................................................................................................................................................... 306

PRCDR_DT7 .......................................................................................................................................................... 306

PRCDR_DT8 .......................................................................................................................................................... 306

PRCDR_DT9 .......................................................................................................................................................... 306

PRCDR_DT10 ........................................................................................................................................................ 306

PRCDR_DT11 ........................................................................................................................................................ 306

PRCDR_DT12 ........................................................................................................................................................ 306

PRCDR_DT13 ........................................................................................................................................................ 306

PRCDR_DT14 ........................................................................................................................................................ 306

PRCDR_DT15 ........................................................................................................................................................ 306

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PRCDR_DT16 ........................................................................................................................................................ 306

PRCDR_DT17 ........................................................................................................................................................ 306

PRCDR_DT18 ........................................................................................................................................................ 306

PRCDR_DT19 ........................................................................................................................................................ 306

PRCDR_DT20 ........................................................................................................................................................ 306

PRCDR_DT21 ........................................................................................................................................................ 306

PRCDR_DT22 ........................................................................................................................................................ 306

PRCDR_DT23 ........................................................................................................................................................ 306

PRCDR_DT24 ........................................................................................................................................................ 306

PRCDR_DT25 ........................................................................................................................................................ 306

PRF_PHYSN_NPI ................................................................................................................................................... 308

PRF_PHYSN_UPIN ................................................................................................................................................. 309

PRNCPAL_DGNS_CD ............................................................................................................................................. 310

PRNCPAL_DGNS_VRSN_CD ................................................................................................................................... 311

PRTCPTNG_IND_CD .............................................................................................................................................. 312

PRVDR_FULL_CCN_NUM ...................................................................................................................................... 313

PRVDR_NPI ........................................................................................................................................................... 314

PRVDR_NUM (Institutional claim) ......................................................................................................................... 315

PRVDR_NUM (DMERC claim) ................................................................................................................................ 320

PRVDR_SPCLTY ..................................................................................................................................................... 321

PRVDR_STATE_CD ................................................................................................................................................ 324

PRVDR_VLDTN_TYPE_CD ...................................................................................................................................... 326

PRVDR_ZIP ............................................................................................................................................................ 327

PTNT_DSCHRG_STUS_CD ...................................................................................................................................... 328

RC_MODEL_REIMBRSMT_AMT ............................................................................................................................. 331

RC_PTNT_ADD_ON_PYMT_AMT ........................................................................................................................... 332

RC_VLNTRY_SRVC_IND_CD ................................................................................................................................... 333

REV_CNTR ............................................................................................................................................................ 334

REV_CNTR_1ST_ANSI_CD ..................................................................................................................................... 353

REV_CNTR_1ST_MSP_PD_AMT ............................................................................................................................. 360

REV_CNTR_2ND_ANSI_CD .................................................................................................................................... 361

REV_CNTR_2ND_MSP_PD_AMT ........................................................................................................................... 368

REV_CNTR_3RD_ANSI_CD ..................................................................................................................................... 369

REV_CNTR_4TH_ANSI_CD ..................................................................................................................................... 376

REV_CNTR_ADJUST_GRP_CD ................................................................................................................................ 383

REV_CNTR_ADJUST_RSN_CD ................................................................................................................................ 384

REV_CNTR_APC_HIPPS_CD ................................................................................................................................... 385

REV_CNTR_BENE_PMT_AMT ................................................................................................................................ 387

REV_CNTR_BLOOD_DDCTBL_AMT ........................................................................................................................ 388

REV_CNTR_CASH_DDCTBL_AMT ........................................................................................................................... 389

REV_CNTR_COINSRNC_WGE_ADJSTD_C ............................................................................................................... 390

REV_CNTR_CRA_TPNIES_AMT .............................................................................................................................. 391

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REV_CNTR_DDCTBL_COINSRNC_CD ...................................................................................................................... 392

REV_CNTR_DSCNT_IND_CD .................................................................................................................................. 393

REV_CNTR_DT ...................................................................................................................................................... 395

REV_CNTR_IDE_NDC_UPC_NUM .......................................................................................................................... 396

REV_CNTR_NCVRD_CHRG_AMT ........................................................................................................................... 397

REV_CNTR_NDC_QTY ........................................................................................................................................... 398

REV_CNTR_NDC_QTY_QLFR_CD ........................................................................................................................... 399

REV_CNTR_OTAF_PMT_CD ................................................................................................................................... 400

REV_CNTR_PACKG_IND_CD .................................................................................................................................. 401

REV_CNTR_PMT_AMT_AMT ................................................................................................................................. 402

REV_CNTR_PMT_MTHD_IND_CD .......................................................................................................................... 403

REV_CNTR_PRCNG_IND_CD .................................................................................................................................. 405

REV_CNTR_PRVDR_PMT_AMT .............................................................................................................................. 408

REV_CNTR_PTNT_RSPNSBLTY_PMT ...................................................................................................................... 409

REV_CNTR_RATE_AMT ......................................................................................................................................... 410

REV_CNTR_RDCD_COINSRNC_AMT ...................................................................................................................... 411

REV_CNTR_RP_IND_CD......................................................................................................................................... 412

REV_CNTR_STUS_IND_CD ..................................................................................................................................... 413

REV_CNTR_RA_RMRK_CD ..................................................................................................................................... 415

REV_CNTR_THRPY_RDCTN_AMT .......................................................................................................................... 416

REV_CNTR_TOT_CHRG_AMT ................................................................................................................................ 417

REV_CNTR_UNIT_CNT........................................................................................................................................... 418

RFR_PHYSN_NPI ................................................................................................................................................... 419

RFR_PHYSN_SPCLTY_CD ....................................................................................................................................... 420

RFR_PHYSN_UPIN ................................................................................................................................................. 423

RLT_COND_CD_SEQ .............................................................................................................................................. 424

RLT_OCRNC_CD_SEQ ............................................................................................................................................ 425

RLT_SPAN_CD_SEQ ............................................................................................................................................... 426

RLT_VAL_CD_SEQ ................................................................................................................................................. 427

RNDRNG_PHYSN_NPI ........................................................................................................................................... 428

RNDRNG_PHYSN_SPCLTY_CD ............................................................................................................................... 429

RNDRNG_PHYSN_UPIN ......................................................................................................................................... 432

RNDRNG_PHYSN_UPIN ......................................................................................................................................... 433

RNDRNG_PRVDR_SPCLTY_CD1 ............................................................................................................................. 434

RNDRNG_PRVDR_SPCLTY_CD2 ............................................................................................................................. 434

RNDRNG_PRVDR_SPCLTY_CD3 ............................................................................................................................. 434

RNDRNG_PRVDR_TXNMY_CD ............................................................................................................................... 437

RR_BRD_EXCLSN_IND_SW .................................................................................................................................... 438

RSN_VISIT_CD1 ..................................................................................................................................................... 439

RSN_VISIT_CD2 ..................................................................................................................................................... 439

RSN_VISIT_CD3 ..................................................................................................................................................... 439

RSN_VISIT_VRSN_CD1 .......................................................................................................................................... 440

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RSN_VISIT_VRSN_CD2 .......................................................................................................................................... 440

RSN_VISIT_VRSN_CD3 .......................................................................................................................................... 440

SRVC_LOC_NPI_NUM ........................................................................................................................................... 441

TAX_NUM ............................................................................................................................................................. 442

THRPY_CAP_IND_CD1 ........................................................................................................................................... 443

THRPY_CAP_IND_CD2 ........................................................................................................................................... 443

THRPY_CAP_IND_CD3 ........................................................................................................................................... 443

THRPY_CAP_IND_CD4 ........................................................................................................................................... 443

THRPY_CAP_IND_CD5 ........................................................................................................................................... 443

TRNSTNL_DRUG_ADD_ON_PYMT_AMT ................................................................................................................ 445

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Variable Details

This section of the codebook contains one entry for each variable in the Medicare fee-for-service claims (version L) files.

Each entry contains variable details to facilitate understanding and use of the variables.

ACO_ID_NUM

LABEL: Claim Accountable Care Organization (ACO) Identification Number

DESCRIPTION: The field identifies the Accountable Care Organization (ACO) Identification Number. This field

populates the benefit enhancement indicators for all models, not just Next Generation ACOs.

SHORT NAME: ACO_ID_NUM

LONG NAME: ACO_ID_NUM

TYPE: CHAR

LENGTH: 10

SOURCE: NCH

VALUES: —

COMMENT: CMS began populating this field in 2016.

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ADMTG_DGNS_CD

LABEL: Claim Admitting Diagnosis Code

DESCRIPTION: A diagnosis code on the institutional claim indicating the beneficiary's initial diagnosis at admission.

This diagnosis code after evaluating the patient; it may be different from the eventual diagnoses (e.g.,

as in PRNCPAL_DGNS_CD or ICD_DGNS_CD1–25).

SHORT NAME: ADMTG_DGNS_CD

LONG NAME: ADMTG_DGNS_CD

TYPE: CHAR

LENGTH: 7

SOURCE: NCH

VALUES: —

COMMENT: —

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ADMTG_DGNS_VRSN_CD

LABEL: Claim Admitting Diagnosis Version Code (ICD-9 or ICD-10)

DESCRIPTION: Effective with version “J,” the code used to indicate if the diagnosis code is ICD-9/ICD-10.

SHORT NAME: ADMTG_DGNS_VRSN_CD

LONG NAME: ADMTG_DGNS_VRSN_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: Blank = ICD-9

9 = ICD-9

0 = ICD-10

COMMENT: On October 1, 2015, the conversion from the 9th version of the International Classification of Diseases

(ICD-9-CM) to version 10 (ICD-10-CM) occurred.

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AT_PHYSN_NPI

LABEL: Claim Attending Physician NPI Number

DESCRIPTION: On an institutional claim, the national provider identifier (NPI) is a unique number assigned to identify

the physician who has overall responsibility for the beneficiary's care and treatment.

NPIs replaced UPINs as the standard provider identifiers beginning in 2007. The UPIN is almost never

populated after 2009.

SHORT NAME: AT_NPI

LONG NAME: AT_PHYSN_NPI

TYPE: CHAR

LENGTH: 10

SOURCE: NCH

VALUES: —

COMMENT: —

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AT_PHYSN_SPCLTY_CD

LABEL: Claim Attending Physician Specialty Code

DESCRIPTION: This variable is the code used to identify the CMS specialty code corresponding to the attending

physician.

SHORT NAME: AT_PHYSN_SPCLTY_CD

LONG NAME: AT_PHYSN_SPCLTY_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES:

00 = Carrier wide

01 = General practice

02 = General surgery

03 = Allergy/immunology

04 = Otolaryngology

05 = Anesthesiology

06 = Cardiology

07 = Dermatology

08 = Family practice

09 = Interventional Pain Management

(IPM) (eff. 4/2003)

10 = Gastroenterology

11 = Internal medicine

12 = Osteopathic manipulative

medicine

13 = Neurology

14 = Neurosurgery

15 = Speech/language pathologist in

private practice

16 = Obstetrics/gynecology

17 = Hospice and Palliative Care

18 = Ophthalmology

19 = Oral surgery (dentists only)

20 = Orthopedic surgery

21 = Cardiac Electrophysiology

22 = Pathology

23 = Sports medicine

24 = Plastic and reconstructive surgery

25 = Physical medicine and

rehabilitation

26 = Psychiatry

27 = Geriatric Psychiatry

28 = Colorectal surgery (formerly proctology)

29 = Pulmonary disease

30 = Diagnostic radiology

31 = Intensive cardiac rehabilitation

32 = Anesthesiologist Assistant (eff. 4/2003 —

previously grouped with Certified Registered

Nurse Anesthetists (CRNA))

33 = Thoracic surgery

34 = Urology

35 = Chiropractic

36 = Nuclear medicine

37 = Pediatric medicine

38 = Geriatric medicine

39 = Nephrology

40 = Hand surgery

41 = Optometry

42 = Certified nurse midwife

43 = Certified Registered Nurse Anesthetist (CRNA)

(Anesthesiologist Assistants were removed from

this specialty 4/1/2003)

44 = Infectious disease

45 = Mammography screening center

46 = Endocrinology

47 = Independent Diagnostic Testing Facility (IDTF)

48 = Podiatry

49 = Ambulatory surgical center (formerly

miscellaneous)

50 = Nurse practitioner

51 = Medical supply company with certified orthotist

(certified by American Board for Certification in

Prosthetics and Orthotics)

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52 = Medical supply company with

certified prosthetist (certified by

American Board for Certification

in Prosthetics and Orthotics)

53 = Medical supply company with

certified prosthetist-orthotist

(certified by American Board for

Certification in Prosthetics and

Orthotics)

54 = Medical supply company for

DMERC (and not included in 51–

53)

55 = Individual certified orthotic

personnel certified by an

accrediting organization

56 = Individual certified prosthetic

personnel certified by an

accrediting organization

57 = Individual certified prosthetic-

orthotic personnel certified by an

accrediting organization

58 = Medical supply company with

registered pharmacist

59 = Ambulance service (private)

60 = Public health or welfare agencies

(federal, state, and local)

61 = Voluntary health or charitable

agencies (e.g., National Cancer

Society, National Heart

Association, Catholic Charities)

62 = Psychologist (billing

independently)

63 = Portable X-ray supplier (billing

independently)

64 = Audiologist (billing independently)

65 = Physical therapist in private

practice

66 = Rheumatology

67 = Occupational therapist in private

practice

68 = Clinical psychologist

69 = Clinical laboratory (billing

independently)

70 = Single or Multispecialty clinic or

group practice (PA Group)

71 = Registered Dietician/Nutrition

Professional (eff. 1/2002)

72 = Pain Management (eff. 1/2002)

73 = Mass Immunization Roster Biller

74 = Radiation Therapy Centers (prior to

4/2003 this included Independent

Diagnostic Testing Facilities (IDTF)

75 = Slide Preparation Facilities (added to

differentiate them from Independent

Diagnostic Testing Facilities (IDTFs —

eff. 4/2003)

76 = Peripheral vascular disease

77 = Vascular surgery

78 = Cardiac surgery

79 = Addiction medicine

80 = Licensed clinical social worker

81 = Critical care (intensivists)

82 = Hematology

83 = Hematology/oncology

84 = Preventive medicine

85 = Maxillofacial surgery

86 = Neuropsychiatry

87 = All other suppliers (e.g., drug stores)

88 = Unknown provider

89 = Certified clinical nurse specialist

90 = Medical oncology

91 = Surgical oncology

92 = Radiation oncology

93 = Emergency medicine

94 = Interventional radiology

95 = Competitive Acquisition Program (CAP)

Vendor (eff. 7/2001/2006). Prior to

7/2001/2006, known as Independent

physiological laboratory

96 = Optician

97 = Physician assistant

98 = Gynecological/oncology

99 = Unknown physician specialty

A0 = Hospital (DMERCs only)

A1 = Skilled nursing facility (DMERCs only)

A2 = Intermediate care nursing facility

(DMERCs only)

A3 = Nursing facility, other (DMERCs only)

A4 = Home health agency (DMERCs only)

A5 = Pharmacy (DMERC)

A6 = Medical supply company with

respiratory therapist (DMERCs only)

A7 = Department store (DMERC)

A8 = Grocery store (DMERC)

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 7

A9 = Indian Health Service (IHS), tribe

and tribal organizations (non-

hospital or non-hospital-based

facilities, eff. 1/2005)

B1 = Supplier of oxygen and/or oxygen

related equipment (eff. 10/2007)

B2 = Pedorthic Personnel (eff.

10/2007)

B3 = Medical Supply Company with

pedorthic personnel (eff.

10/2007)

B4 = Does not meet definition of

health care provider (e.g.,

Rehabilitation agency, organ

procurement organizations,

histocompatibility labs) (eff.

10/2007)

B5 = Ocularist

C0 = Sleep medicine

C1 = Centralized flu

C2 = Indirect payment procedure

C3 = Interventional cardiology

C5 = Dentist (eff. 7/2016)

C6 = Hospitalist

C7 = Advanced heart failure and

transplant cardiology

C8 = Medical toxicology

C9 = Hematopoietic cell transplantation

and cellular therapy

D3 = Medical genetics and genomics

D4 = Undersea and Hyperbaric Medicine

D5 = Opioid Treatment Program (eff.

1/2020)

D7 = Micrographic Dermatologic Surgery

(MDS) (eff. 10/2020)

D8 = Adult Congenital Heart Disease

E1 = Marriage and Family Therapists

E2 = Mental Health Counselors

E3 = Dental Anesthesiology

E4 = Dental Public Health

E5 = Endodontics

E6 = Oral and Maxillofacial Pathology

E7 = Oral and Maxillofacial Radiology

E9 = Oral Medicine

F1 = Orofacial Pain

F2 = Orthodontics and Dentofacial

Orthopedics

F3 = Pediatric Dentistry

F4 = Periodontics

F5 = Prosthodontics

COMMENT: CMS added this field to accommodate the Affordable Care Act (ACA) — for incentive payments to

providers with specific primary care specialty designations. It was not populated before 2012. This

field is not populated on inpatient or Skilled Nursing claims.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 8

AT_PHYSN_UPIN

LABEL: Claim Attending Physician UPIN Number

DESCRIPTION: On an institutional claim, the unique physician identification number (UPIN) of the physician who

would normally be expected to certify and recertify the medical necessity of the services rendered

and/or who has primary responsibility for the beneficiary's medical care and treatment (attending

physician).

NPIs replaced UPINs as the standard provider identifiers beginning in 2007. The UPIN is almost never

populated after 2009.

SHORT NAME: AT_UPIN

LONG NAME: AT_PHYSN_UPIN

TYPE: CHAR

LENGTH: 6

SOURCE: NCH

VALUES: —

COMMENT: —

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 9

BENE_CNTY_CD

LABEL: County Code from Claim (SSA)

DESCRIPTION: The 3-digit social security administration (SSA) standard county code of a beneficiary's residence.

SHORT NAME: CNTY_CD

LONG NAME: BENE_CNTY_CD

TYPE: CHAR

LENGTH: 3

SOURCE: SSA/EDB

VALUES: —

COMMENT: The US Census website lists county codes. Also, CMS has core-based statistical area (CBSA) crosswalk

files available on their website, which include state and county SSA codes.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 10

BENE_HOSPC_PRD_CNT

LABEL: Beneficiary's Hospice Period Count

DESCRIPTION: The count of the number of hospice period trailers present for the beneficiary's record.

Medicare covers hospice benefit periods, consisting of two initial 90-day periods followed by an

unlimited number of 60-day periods.

Hospice benefits are generally in lieu of standard Part A hospital benefits for treating the terminal

condition.

SHORT NAME: HOSPCPRD

LONG NAME: BENE_HOSPC_PRD_CNT

TYPE: NUM

LENGTH: 1

SOURCE: NCH

VALUES: —

COMMENT: A series of Medicare Payment Advisory Commission (MedPAC) documents called “Payment Basics”

describe Medicare payments in detail. (reference: https://www.medpac.gov/document-

type/payment-basic/)

Also, in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series”

(reference: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/html/medicare-payment-systems.html#Hospice)

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 11

BENE_ID

LABEL: Encrypted CCW Beneficiary ID

DESCRIPTION: The unique CCW identifier for a beneficiary.

The CCW assigns a unique beneficiary identification number to each individual who receives Medicare

and/or Medicaid and uses that number to identify an individual’s records in all CCW data files (e.g.,

Medicare claims, MAX claims, T-MSIS claims, and MDS assessment data).

This number does not change during a beneficiary’s lifetime, and CCW uses each number only once.

The BENE_ID is specific to the CCW and is not applicable to any other identification system or data

source.

SHORT NAME: BENE_ID

LONG NAME: BENE_ID

TYPE: CHAR

LENGTH: 15

SOURCE: CCW

VALUES: —

COMMENT: —

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 12

BENE_LRD_USED_CNT

LABEL: Beneficiary Medicare Lifetime Reserve Days (LRD) Used Count

DESCRIPTION: The number of lifetime reserve days that the beneficiary has elected to use during the period covered

by the institutional claim.

Under Medicare, each beneficiary has a one-time reserve of sixty additional days of inpatient hospital

coverage that the patient can use after 90 days of inpatient care have been provided in a single

benefit period.

This count subtracts from the total number of lifetime reserve days that a beneficiary has available.

SHORT NAME: LRD_USE

LONG NAME: BENE_LRD_USED_CNT

TYPE: NUM

LENGTH: 3

SOURCE: NCH

VALUES: —

COMMENT: —

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 13

BENE_MLG_CNTCT_ZIP_CD

LABEL: ZIP Code of Residence from Claim

DESCRIPTION: The beneficiaries’ mailing address ZIP code.

SHORT NAME: ZIP_CD

LONG NAME: BENE_MLG_CNTCT_ZIP_CD

TYPE: CHAR

LENGTH: 9

SOURCE: EDB

VALUES: —

COMMENT: —

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 14

BENE_RACE_CD

LABEL: Beneficiary Race Code

DESCRIPTION: Race code from claim

SHORT NAME: RACE_CD

LONG NAME: BENE_RACE_CD

TYPE: CHAR

LENGTH: 1

SOURCE: SSA

VALUES: 0 = Unknown

1 = White

2 = Black

3 = Other

4 = Asian

5 = Hispanic

6 = North American Native

COMMENT: —

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 15

BENE_STATE_CD

LABEL: Beneficiary Residence (SSA) State Code

DESCRIPTION: The social security administration (SSA) standard 2-digit state code of a beneficiary's residence.

SHORT NAME: STATE_CD

LONG NAME: BENE_STATE_CD

TYPE: CHAR

LENGTH: 2

SOURCE: SSA/EDB

VALUES:

01 = Alabama

02 = Alaska

03 = Arizona

04 = Arkansas

05 = California

06 = Colorado

07 = Connecticut

08 = Delaware

09 = District of Columbia

10 = Florida

11 = Georgia

12 = Hawaii

13 = Idaho

14 = Illinois

15 = Indiana

16 = Iowa

17 = Kansas

18 = Kentucky

19 = Louisiana

20 = Maine

21 = Maryland

22 = Massachusetts

23 = Michigan

24 = Minnesota

25 = Mississippi

26 = Missouri

27 = Montana

28 = Nebraska

29 = Nevada

30 = New Hampshire

31 = New Jersey

32 = New Mexico

33 = New York

34 = North Carolina

35 = North Dakota

36 = Ohio

37 = Oklahoma

38 = Oregon

39 = Pennsylvania

40 = Puerto Rico

41 = Rhode Island

42 = South Carolina

43 = South Dakota

44 = Tennessee

45 = Texas

46 = Utah

47 = Vermont

48 = Virgin Islands

49 = Virginia

50 = Washington

51 = West Virginia

52 = Wisconsin

53 = Wyoming

54 = Africa

55 = Asia

56 = Canada

57 = Central America and West Indies

58 = Europe

59 = Mexico

60 = Oceania

61 = Philippines

62 = South America

63 = U.S. Possessions

64 = American Samoa

65 = Guam

97 = Northern Marianas

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 16

98 = Guam 99 = Unknown or if county code = 000 then this is

American Samoa

COMMENT: —

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 17

BENE_TOT_COINSRNC_DAYS_CNT

LABEL: Beneficiary Total Coinsurance Days Count

DESCRIPTION: The count of the total number of coinsurance days involved with the beneficiary's stay in a facility.

During each benefit period (calendar year), the beneficiary is responsible for coinsurance for particular

days of inpatient care (no coinsurance from day 1 through day 60, then for days 61 through 90 there is

25% coinsurance), SNF care (no coinsurance until day 21, then is 1/8 of inpatient hospital deductible

amount through 100th day of SNF).

Different rules apply for lifetime reserve days, etc.

SHORT NAME: COIN_DAY

LONG NAME: BENE_TOT_COINSRNC_DAYS_CNT

TYPE: NUM

LENGTH: 3

SOURCE: NCH

VALUES: —

COMMENT: —

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 18

BETOS_CD

LABEL: Line Berenson-Eggers Type of Service (BETOS) Code

DESCRIPTION: The Berenson-Eggers Type of Service (BETOS) for the procedure code based on generally agreed upon

clinically meaningful groupings of procedures and services.

This field is included on the NCH claims as a line item on the non-institutional claim.

SHORT NAME: BETOS

LONG NAME: BETOS_CD

TYPE: CHAR

LENGTH: 3

SOURCE: NCH

VALUES:

M1A = Office visits — new

M1B = Office visits — established

M2A = Hospital visit — initial

M2B = Hospital visit — subsequent

M2C = Hospital visit — critical care

M3 = Emergency room visit

M4A = Home visit

M4B = Nursing home visit

M5A = Specialist — pathology

M5B = Specialist — psychiatry

M5C = Specialist — ophthalmology

M5D = Specialist — other

M6 = Consultations

P0 = Anesthesia

P1A = Major procedure — breast

P1B = Major procedure — colectomy

P1C = Major procedure —

cholecystectomy

P1D = Major procedure — turp

P1E = Major procedure —

hysterectomy

P1F = Major procedure —

explor/decompr/excisdisc

P1G = Major procedure — Other

P2A = Major procedure,

cardiovascular—CABG

P2B = Major procedure,

cardiovascular—Aneurysm

repair

P2C = Major procedure, cardiovascular —

Thromboendarterectomy

P2D = Major procedure, cardiovascular —

Coronary angioplasty (PTCA)

P2E = Major procedure, cardiovascular —

Pacemaker insertion

P2F = Major procedure, cardiovascular —

Other

P3A = Major procedure, orthopedic — Hip

fracture repair

P3B = Major procedure, orthopedic — Hip

replacement

P3C = Major procedure, orthopedic — Knee

replacement

P3D = Major procedure, orthopedic — other

P4A = Eye procedure — corneal transplant

P4B = Eye procedure — cataract

removal/lens insertion

P4C = Eye procedure — retinal detachment

P4D = Eye procedure — treatment of retinal

lesions

P4E = Eye procedure — other

P5A = Ambulatory procedures — skin

P5B = Ambulatory procedures —

musculoskeletal

P5C = Ambulatory procedures — inguinal

hernia repair

P5D = Ambulatory procedures — lithotripsy

P5E = Ambulatory procedures — other

P6A = Minor procedures — skin

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 19

P6B = Minor procedures —

musculoskeletal

P6C = Minor procedures — other

(Medicare fee schedule)

P6D = Minor procedures — other

(non-Medicare fee schedule)

P7A = Oncology — radiation therapy

P7B = Oncology — other

P8A = Endoscopy — arthroscopy

P8B = Endoscopy — upper

gastrointestinal

P8C = Endoscopy — sigmoidoscopy

P8D = Endoscopy — colonoscopy

P8E = Endoscopy — cystoscopy

P8F = Endoscopy — bronchoscopy

P8G = Endoscopy — laparoscopic

cholecystectomy

P8H = Endoscopy — laryngoscopy

P8I = Endoscopy — other

P9A = Dialysis services (Medicare fee

schedule)

P9B = Dialysis services (non-Medicare

fee schedule)

I1A = Standard imaging — chest

I1B = Standard imaging —

musculoskeletal

I1C = Standard imaging — breast

I1D = Standard imaging — contrast

gastrointestinal

I1E = Standard imaging — nuclear

medicine

I1F = Standard imaging — other

I2A = Advanced imaging —

CAT/CT/CTA: brain/head/neck

I2B = Advanced imaging —

CAT/CT/CTA: other

I2C = Advanced imaging — MRI/MRA:

brain/head/neck

I2D = Advanced imaging — MRI/MRA:

other

I3A = Echography/ultrasonography —

eye

I3B = Echography/ultrasonography — abdomen/pelvis

I3C = Echography/ultrasonography — heart

I3D = Echography/ultrasonography — carotid arteries

I3E = Echography/ultrasonography — prostate,

transrectal

I3F = Echography/ultrasonography — other

I4A = Imaging/procedure — heart including cardiac

catheterization

I4B = Imaging/procedure — other

T1A = Lab tests — routine venipuncture (non-Medicare

fee schedule)

T1B = Lab tests — automated general profiles

T1C = Lab tests — urinalysis

T1D = Lab tests — blood counts

T1E = Lab tests — glucose

T1F = Lab tests — bacterial cultures

T1G = Lab tests — other (Medicare fee schedule)

T1H = Lab tests — other (non-Medicare fee schedule)

T2A = Other tests — electrocardiograms

T2B = Other tests — cardiovascular stress tests

T2C = Other tests — EKG monitoring

T2D = Other tests — other

D1A = Medical/surgical supplies

D1B = Hospital beds

D1C = Oxygen and supplies

D1D = Wheelchairs

D1E = Other DME

D1F = Prosthetic/Orthotic devices

D1G = Drugs Administered through DME

O1A = Ambulance

O1B = Chiropractic

O1C = Enteral and parenteral

O1D = Chemotherapy

O1E = Other drugs

O1F = Hearing and speech services

O1G = Immunizations/Vaccinations

Y1 = Other — Medicare fee schedule

Y2 = Other — non-Medicare fee schedule

Z1 = Local codes

Z2 = Undefined codes

COMMENT: CMS derives this field using a Healthcare Common Procedure Coding System (HCPCS) code to BETOS

code crosswalk.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 20

BLG_PRVDR_SPCLTY_CD1

BLG_PRVDR_SPCLTY_CD2

BLG_PRVDR_SPCLTY_CD3

LABEL: Claim Billing Provider Secondary Specialty Code (1–3)

DESCRIPTION: The CMS secondary specialty code(s) assigned to the billing provider’s National Provider Identifier

(NPI). These specialty codes apply to the carrier claim billing NPI number (CARR_CLM_BLG_NPI_NUM).

SHORT NAME: BLG_PRVDR_SPCLTY_CD1

BLG_PRVDR_SPCLTY_CD2

BLG_PRVDR_SPCLTY_CD3

LONG NAME: BLG_PRVDR_SPCLTY_CD1

BLG_PRVDR_SPCLTY_CD2

BLG_PRVDR_SPCLTY_CD3

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES:

00 = Carrier wide

01 = General practice

02 = General surgery

03 = Allergy/immunology

04 = Otolaryngology

05 = Anesthesiology

06 = Cardiology

07 = Dermatology

08 = Family practice

09 = Interventional Pain Management

(IPM) (eff. 4/2003)

10 = Gastroenterology

11 = Internal medicine

12 = Osteopathic manipulative therapy

13 = Neurology

14 = Neurosurgery

15 = Speech/language pathology

16 = Obstetrics/gynecology

17 = Hospice and palliative care

18 = Ophthalmology

19 = Oral surgery (dentists only)

20 = Orthopedic surgery

21 = Cardiac electrophysiology

22 = Pathology

23 = Sports medicine

24 = Plastic and reconstructive surgery

25 = Physical medicine and rehabilitation

26 = Psychiatry

27 = General psychiatry

28 = Colorectal surgery (formerly

proctology)

29 = Pulmonary disease

30 = Diagnostic radiology

31 = Intensive cardiac rehabilitation

32 = Anesthesiologist Assistants (eff.

4/2003 — previously grouped

with Certified Registered Nurse

Anesthetists [CRNA])

33 = Thoracic surgery

34 = Urology

35 = Chiropractic

36 = Nuclear medicine

37 = Pediatric medicine

38 = Geriatric medicine

39 = Nephrology

40 = Hand surgery

41 = Optometrist

42 = Certified nurse midwife

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 21

43 = Certified Registered Nurse

Anesthetist (CRNA)

(Anesthesiologist assistants were

removed from this specialty

4/1/2003)

44 = Infectious disease

45 = Mammography screening center

46 = Endocrinology

47 = Independent diagnostic testing

facility (IDTF)

48 = Podiatry

49 = Ambulatory surgical center

(formerly miscellaneous)

50 = Nurse practitioner

51 = Medical supply company with

certified orthotist (certified by

American Board for Certification

in Prosthetics and Orthotics)

52 = Medical supply company with

certified prosthetist (certified by

American Board for Certification

in Prosthetics and Orthotics)

53 = Medical supply company with

certified prosthetist-orthotist

(certified by American Board for

Certification in Prosthetics and

Orthotics)

54 = Medical supply company for

DMERC (and not included in 51–

53)

55 = Individual certified orthotist

56 = Individual certified prosthetist

57 = Individual certified prosthetist-

orthotist

58 = Medical supply company with

registered pharmacist

59 = Ambulance service supplier, (e.g.,

private ambulance companies,

funeral homes, etc.)

60 = Public health or welfare agencies

(federal, state, and local)

61 = Voluntary health or charitable

agencies (e.g., National Cancer

Society, National Heart

Association, Catholic Charities)

62 = Psychologist (billing

independently)

63 = Portable X-ray supplier

64 = Audiologist (billing independently)

65 = Physical therapist (private practice

added 4/1/2003) (independently

practicing removed 4/1/2003)

66 = Rheumatology

67 = Occupational therapist (private

practice added 4/1/2003)

(independently practicing removed

4/1/2003)

68 = Clinical psychologist

69 = Clinical laboratory (billing

independently)

70 = Single or multispecialty clinic or

group practice

71 = Registered dietician/Nutrition

professional (eff. 1/2002)

72 = Pain management (eff. 1/2002)

73 = Mass immunization roster biller

74 = Radiation therapy centers (prior to

4/2003 this included independent

diagnostic testing facilities (IDTF)

75 = Slide preparation facilities (added

to differentiate them from

independent diagnostic testing

facilities (IDTFs — eff. 4/2003)

76 = Peripheral vascular disease

77 = Vascular surgery

78 = Cardiac surgery

79 = Addiction medicine

80 = Licensed clinical social worker

81 = Critical care (intensivists)

82 = Hematology

83 = Hematology/Oncology

84 = Preventive medicine

85 = Maxillofacial surgery

86 = Neuropsychiatry

87 = All other suppliers (e.g., drug and

department stores)

88 = Unknown supplier/Provider

specialty

89 = Certified clinical nurse specialist

90 = Medical oncology

91 = Surgical oncology

92 = Radiation oncology

93 = Emergency medicine

94 = Interventional radiology

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 22

95 = Competitive Acquisition Program

(CAP) vendor (eff. 7/2001/2006)

Prior to 07/2001/2006, known as

independent physiological

laboratory

96 = Optician

97 = Physician assistant

98 = Gynecologist/oncologist

99 = Unknown physician specialty

A0 = Hospital (DMERCs only)

A1 = SNF (DMERCs only)

A2 = Intermediate care nursing facility

(DMERCs only)

A3 = Nursing facility, other (DMERCs

only)

A4 = Home health agency (DMERCs

only)

A5 = Pharmacy (DMERC)

A6 = Medical supply company with

respiratory therapist (DMERCs

only)

A7 = Department store (DMERC)

A8 = Grocery store (DMERC)

A9 = Indian Health Service (IHS), tribe

and tribal organizations (non-

hospital or non-hospital-based

facilities, eff. 1/2005)

B1 = Supplier of oxygen and/or oxygen

related equipment (eff. 10/2007)

B2 = Pedorthic Personnel (eff.

10/2007)

B3 = Medical Supply Company with

pedorthic personnel (eff.

10/2007)

B4 = Does not meet definition of health

care provider (e.g., rehabilitation

agency, organ procurement

organizations, histocompatibility labs)

(eff. 10/2007)

B5 = Ocularist

C0 = Sleep medicine

C1 = Centralized flu

C2 = Indirect payment procedure

C3 = Interventional cardiology

C5 = Dentist

C6 = Hospitalist

C7 = Advanced heart failure and

transplant cardiology

C8 = Medical toxicology

C9 = Hematopoietic cell transplantation and

cellular therapy

D3 = Medical genetics and genomics

D4 = Undersea and hyperbaric medicine

D5 = Opioid treatment program (eff. 1/2020)

D7 = Micrographic dermatologic surgery

D8 = Adult congenital heart disease

E1 = Marriage and family therapists

E2 = Mental health counselors

E3 = Dental anesthesiology

E4 = Dental public health

E5 = Endodontics

E6 = Oral and maxillofacial pathology

E7 = Oral and maxillofacial radiology

E9 = Oral medicine

F1 = Orofacial pain

F2 = Orthodontics and dentofacial orthopedics

F3 = Pediatric dentistry

F4 = Periodontics

F5 = Prosthodontics

COMMENT: These fields are added to the data file October 2023. The primary specialty code for the rendering

provider is “LINE_HCFA_PRVDR_SPCLTY_CD.” These codes are all secondary-specialty codes — not

primary specialty codes, just additional specialties that the provider has.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 23

BLG_PRVDR_TXNMY_CD

LABEL: Claim Billing Provider Taxonomy Code

DESCRIPTION: The taxonomy code assigned to the billing provider’s National Provider Identifier (NPI). A taxonomy

code is a unique 10-character code that assigns a provider's classification and specialization. Providers

use this code when applying for a National Provider Identifier (NPI).This taxonomy code applies to the

carrier claim billing NPI number (CARR_CLM_BLG_NPI_NUM).

SHORT NAME: BLG_PRVDR_TXNMY_CD

LONG NAME: BLG_PRVDR_TXNMY_CD

TYPE: CHAR

LENGTH: 10

SOURCE: NCH

VALUES: —

COMMENT: This field was added to the data file October 2023.

This code set is an external code set maintained by the National Uniform Claim Committee (NUCC)

(https://www.nucc.org/index.php).

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 24

CARR_CLM_BLG_NPI_NUM

LABEL: Carrier Claim Billing NPI Number

DESCRIPTION: The CMS National Provider Identifier (NPI) number assigned to the billing provider.

SHORT NAME: CARR_CLM_BLG_NPI_NUM

LONG NAME: CARR_CLM_BLG_NPI_NUM

TYPE: CHAR

LENGTH: 10

SOURCE: NCH

VALUES: —

COMMENT: —

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 25

CARR_CLM_CASH_DDCTBL_APLD_AMT

LABEL: Carrier Claim Cash Deductible Applied Amount (sum of all line-level deductible amounts)

DESCRIPTION: The amount of the cash deductible as submitted on the claim.

This variable is the beneficiary’s liability under the annual Part B deductible for all line items on the

claim; it is the sum of all line-level deductible amounts. (variable called

LINE_BENE_PTB_DDCTBL_AMT)

The Part B deductible applies to both institutional (e.g., HOP) and non-institutional (e.g., carrier and

DME) services.

SHORT NAME: DEDAPPLY

LONG NAME: CARR_CLM_CASH_DDCTBL_APLD_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: The Medicare.gov website describes beneficiaries’ costs in detail. There is a CMS publication called

"Your Medicare Benefits," which explains the deductibles.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 26

CARR_CLM_ENTRY_CD

LABEL: Carrier Claim Entry Code

DESCRIPTION: Carrier-generated code describing whether the Part B claim is an original debit, full credit, or

replacement debit.

SHORT NAME: ENTRY_CD

LONG NAME: CARR_CLM_ENTRY_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: 1 = Original debit; void of original debit (If CLM_DISP_CD = 3, code 1 means voided original debit)

3 = Full credit

5 = Replacement debit

9 = Accrete bill history only

COMMENT: —

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 27

CARR_CLM_HCPCS_YR_CD

LABEL: Claim Healthcare Common Procedure Coding System (HCPCS) Year Code

DESCRIPTION: The Healthcare Common Procedure Coding System (HCPCS) uses this terminal digit to code the claim.

SHORT NAME: HCPCS_YR

LONG NAME: CARR_CLM_HCPCS_YR_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: 1 = 2011

2 = 2012

3 = 2013

4 = 2014

etc.

COMMENT: —

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 28

CARR_CLM_PMT_DNL_CD

LABEL: Carrier Claim Payment Denial Code

DESCRIPTION: The code on a non-institutional claim indicating who receives payment or if the claim was denied.

SHORT NAME: PMTDNLCD

LONG NAME: CARR_CLM_PMT_DNL_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES: Only one-byte was used until 1/2011 (currently, either 1- or 2-byte values may be used, symbols not

currently allowed)

0 = Denied

1 = Physician/Supplier

2 = Beneficiary

3 = Both physician/supplier and

beneficiary

4 = Hospital (hospital-based

physicians)

5 = Both hospital and beneficiary

6 = Group practice prepayment plan

7 = Other entries (e.g., Employer,

union)

8 = Federally funded

9 = PA service

A = Beneficiary under limitation of

liability

B = Physician/Supplier under limitation

of liability

D = Denied due to demonstration

involvement

E = MSP cost avoided IRS/SSA/HCFA

data match (after 01/2001 is first

claim development)

F = MSP cost avoided HMO rate cell

(after 1/2001 is trauma code

development)

G = MSP cost avoided litigation

settlement (after 1/2001 is

secondary claims investigation)

H = MSP cost avoided employer

voluntary reporting (after 1/2001

is self-reports)

J = MSP cost avoided insurer voluntary

reporting (eff. 7/2000)

K = MSP cost avoided initial enrollment

questionnaire (eff. 7/2000)

P = Physician ownership denial

Q = MSP cost avoided — voluntary

agreements including with employer

T = MSP cost avoided — initial enrollment

questionnaire

U = MSP cost avoided — HMO rate cell

adjustment

V = MSP cost avoided — litigation

settlement

X = MSP cost avoided — generic

Y = MSP cost avoided — IRS/SSA data

match

00 = MSP cost avoided — COB contractor

12 = MSP cost avoided — BC/BS voluntary

data sharing agreements (VDSA)

13 = MSP cost avoided — Office of

Personnel Management (OPM) data

match

14 = MSP cost avoided — workman's

compensation (WC) data match

15 = MSP cost avoided — workman's

compensation insurer voluntary data

sharing agreements (WC VDSA)

16 = MSP cost avoided — liability insurer

VDSA

17 = MSP cost avoided — no-fault insurer VDSA

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 29

18 = MSP cost avoided — pharmacy

benefit manager data sharing

agreement

19 = MSP cost avoided — worker’s

compensation Medicare set-

aside arrangement (eff. 4/2006)

21 = MSP cost avoided — MIR

group health plan

22 = MSP cost avoided — MIR non-

group health plan

25 = MSP cost avoided — recovery audit

contractor — California

26 = MSP cost avoided — recovery audit

contractor — Florida

41 = MSP cost avoided — non-group

health plan non-ongoing

responsibility for medical (ORM)

43 = MSP cost avoided — Medicare Part

C/Medicare Advantage

Prior to 2011, the following 1-byte character codes were also valid (these characters preceded use of

2-byte codes, above):

! = MSP cost avoided — COB

contractor (converted to “00” 2-

byte code)

@ = MSP cost avoided — BC/BS

voluntary agreements (converted

to “12” 2-byte code)

# = MSP cost avoided — Office of

Personnel Management

(converted to “13” 2-byte code)

$ = MSP cost avoided —

workman's compensation (WC)

data match (converted to “14” 2-

byte code)

* = MSP cost avoided —

workman's compensation insurer

voluntary data sharing

agreements (WC VDSA) (eff.

4/2006) (converted to “15” 2-byte

code)

( = MSP cost avoided — liability

insurer VDSA (eff. 4/2006)

(converted to “16” 2-byte code)

) = MSP cost avoided — no-fault

insurer VDSA (eff. 4/2006)

(converted to “17” 2-byte code)

+ = MSP cost avoided — pharmacy

benefit manager data sharing

agreement (eff. 4/2006) (converted

to “18” 2-byte code)

< = MSP cost avoided — MIR group

health plan (eff. 1/2009) (converted

to “21” 2-byte code)

> = MSP cost avoided — MIR non-

group health plan (eff. 1/2009)

(converted to “22” 2-byte code)

% = MSP cost avoided — recovery

audit contractor — California (eff.

10/2005) (converted to “25” 2-byte

code)

& = MSP cost avoided — recovery

audit contractor — Florida (eff.

10/2005) (converted to “26” 2-byte

code)

COMMENT: Effective with version “J,” the field was expanded on the NCH record to 2 bytes, with his expansion,

the NCH will no longer use the character values to represent the official two-byte values sent in by

NCH since 4/2002. During the version J conversion, all character values were converted to the two-

byte values.

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 30

On 4/1/2002, this field was expanded to two bytes to accommodate new values. The NCH nearline file

did not expand the current 1-byte field but instituted a crosswalk of the 2-byte field to the 1-byte

character value.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 31

CARR_CLM_PRVDR_ASGNMT_IND_SW

LABEL: Carrier Claim Provider Assignment Indicator Switch

DESCRIPTION: Variable indicates whether or not the provider accepts assignment for the non-institutional claim.

SHORT NAME: ASGMNTCD

LONG NAME: CARR_CLM_PRVDR_ASGNMT_IND_SW

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: A = Assigned claim

N = Non-assigned claim

COMMENT: —

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 32

CARR_CLM_RFRNG_PIN_NUM

LABEL: Carrier Claim Referring Provider ID Number (PIN)

DESCRIPTION: The provider identification number (PIN) of the physician/supplier (assigned by the MAC) who referred

the beneficiary to the physician who ordered these services.

SHORT NAME: RFR_PRFL

LONG NAME: CARR_CLM_RFRNG_PIN_NUM

TYPE: CHAR

LENGTH: 14

SOURCE: NCH

VALUES: —

COMMENT: CMS identifies providers using the National Provider Identifier (NPI; eff. 5/2007), which replaces legacy

numbers (UPINs, PINs, etc.) on the standard HIPPA claim transactions.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 33

CARR_CLM_SOS_NPI_NUM

LABEL: Carrier Claim Site of Service NPI Number

DESCRIPTION: This field identifies the site of service National Provider Identifier (NPI).

SHORT NAME: CARR_CLM_SOS_NPI_NUM

LONG NAME: CARR_CLM_SOS_NPI_NUM

TYPE: CHAR

LENGTH: 10

SOURCE: NCH

VALUES: —

COMMENT: This field is not populated prior to 2009.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 34

CARR_LINE_ANSTHSA_UNIT_CNT

LABEL: Carrier Line Anesthesia Unit Count

DESCRIPTION: The base number of units assigned to the line-item anesthesia procedure on the carrier claim (non-

DMERC).

SHORT NAME: CARR_LINE_ANSTHSA_UNIT_CNT

LONG NAME: CARR_LINE_ANSTHSA_UNIT_CNT

TYPE: NUM

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: This field may have decimals (it is formatted as SAS length 11.3). Prior to version “J,” this field was

S9(3), length 7.3.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 35

CARR_LINE_CL_CHRG_AMT

LABEL: Carrier Line Clinical Lab Charge Amount

DESCRIPTION: Clinical lab charge amount on the carrier line.

SHORT NAME: CARR_LINE_CL_CHRG_AMT

LONG NAME: CARR_LINE_CL_CHRG_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: —

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 36

CARR_LINE_CLIA_LAB_NUM

LABEL: Clinical Laboratory Improvement Amendments (CLIA) monitored laboratory number

DESCRIPTION: The identification number assigned to the clinical laboratory providing services for the line item on the

carrier claim (non-DMERC).

SHORT NAME: CARR_LINE_CLIA_LAB_NUM

LONG NAME: CARR_LINE_CLIA_LAB_NUM

TYPE: CHAR

LENGTH: 10

SOURCE: NCH

VALUES: —

COMMENT: —

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 37

CARR_LINE_MDPP_NPI_NUM

LABEL: Carrier Line Medicare Diabetes Prevention Program (MDPP) NPI Number

DESCRIPTION: This field represents the National Provider Identifier (NPI) of the Medicare Diabetes Prevention

Program (MDPP) coach.

SHORT NAME: CARR_LINE_MDPP_NPI_NUM

LONG NAME: CARR_LINE_MDPP_NPI_NUM

TYPE: CHAR

LENGTH: 10

SOURCE: NCH

VALUES: —

COMMENT: This field is new in April 2018.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 38

CARR_LINE_MTUS_CD

LABEL: Carrier Line Miles/Time/Units/Services (MTUS) Indicator Code

DESCRIPTION: Code indicating the units associated with services needing unit reporting on the line item for the

carrier claim (non-DMERC).

SHORT NAME: MTUS_IND

LONG NAME: CARR_LINE_MTUS_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: 0 = Values reported as zero (no allowed activities)

1 = Transportation (ambulance) miles

2 = Anesthesia time units

3 = Services

4 = Oxygen units

5 = Units of blood

COMMENT: —

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 39

CARR_LINE_MTUS_CNT

LABEL: Carrier Line Miles/Time/Units/Services (MTUS) Count

DESCRIPTION: The count of the total units associated with services needing unit reporting such as transportation,

miles, anesthesia time units, number of services, volume of oxygen or blood units.

This is a line-item field on the carrier claim (non-DMERC) and is used for both allowed and denied

services.

SHORT NAME: MTUS_CNT

LONG NAME: CARR_LINE_MTUS_CNT

TYPE: NUM

LENGTH: 11

SOURCE: NCH

VALUES: —

COMMENT: For anesthesia (MTUS indicator = 2) this field should be reported in time unit intervals, e.g., 15-minute

intervals or fraction thereof.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 40

CARR_LINE_PRCNG_LCLTY_CD

LABEL: Carrier Line Pricing Locality Code

DESCRIPTION: Code denoting the carrier-specific locality used for pricing the service for this line item on the carrier

claim (non-DMERC).

SHORT NAME: LCLTY_CD

LONG NAME: CARR_LINE_PRCNG_LCLTY_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES: Medicare localities

There are currently 89 total PFS localities; 34 localities are statewide areas (that is, only one locality for

the entire state).

There are 52 localities in the other 16 states, with 10 states having 2 localities, 2 states having 3

localities, 1 state having 4 localities, and 3 states having 5 or more localities.

The District of Columbia, Maryland, and Virginia suburbs, Puerto Rico, and the Virgin Islands are

additional localities that make up the remainder of the total of 89 localities.

1 = ALABAMA

2 = ALASKA

3 = ARIZONA

4 = ARKANSAS

5 = ANAHEIM/SANTA ANA, CA

6 = LOS ANGELES, CA

7 = MARIN/NAPA/SOLANO, CA

8 = OAKLAND/BERKELEY, CA

9 = REST OF CALIFORNIA

10 = SAN FRANCISCO, CA

11 = SAN MATEO, CA

12 = SANTA CLARA, CA

13 = VENTURA, CA

14 = COLORADO

15 = CONNECTICUT

16 = DC + MD/VA SUBURBS

17 = DELAWARE

18 = FORT LAUDERDALE, FL

19 = MIAMI, FL

20 = REST OF FLORIDA

21 = ATLANTA, GA

22 = REST OF GEORGIA

23 = HAWAII

24 = IDAHO

25 = CHICAGO, IL

26 = EAST ST. LOUIS, IL

27 = REST OF ILLINOIS

28 = SUBURBAN CHICAGO, IL

29 = INDIANA

30 = IOWA

31 = KANSAS

32 = KENTUCKY

33 = NEW ORLEANS, LA

34 = REST OF LOUISIANA

35 = REST OF MAINE

36 = SOUTHERN MAINE

37 = BALTIMORE/SURR. CNTYS, MD

38 = REST OF MARYLAND

39 = METROPOLITAN BOSTON

40 = REST OF MASSACHUSETTS

41 = DETROIT, MI

42 = REST OF MICHIGAN

43 = MINNESOTA

44 = MISSISSIPPI

45 = METROPOLITAN KANSAS CITY, MO

46 = METROPOLITAN ST. LOUIS, MO

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 41

47 = REST OF MISSOURI

48 = MONTANA

49 = NEBRASKA

50 = NEVADA

51 = NEW HAMPSHIRE

52 = NORTHERN NJ

53 = REST OF NEW JERSEY

54 = NEW MEXICO

55 = MANHATTAN, NY

56 = NYC SUBURBS/LONG I., NY

57 = POUGHKPSIE/N NYC SUBURBS,

58 = QUEENS, NY

59 = REST OF NEW YORK

60 = NORTH CAROLINA

61 = NORTH DAKOTA

62 = OHIO

63 = OKLAHOMA

64 = PORTLAND, OR

65 = REST OF OREGON

66 = METROPOLITAN

PHILADELPHIA, PA

67 = REST OF PENNSYLVANIA

68 = PUERTO RICO

69 = RHODE ISLAND

70 = SOUTH CAROLINA

71 = SOUTH DAKOTA

72 = TENNESSEE

73 = AUSTIN, TX

74 = BEAUMONT, TX

75 = BRAZORIA, TX

76 = DALLAS, TX

77 = FORT WORTH, TX

78 = GALVESTON, TX

79 = HOUSTON, TX

80 = REST OF TEXAS

81 = UTAH

82 = VERMONT

83 = VIRGIN ISLANDS

84 = VIRGINIA

85 = REST OF WASHINGTON

86 = SEATTLE (KING CNTY), WA

87 = WEST VIRGINIA

88 = WISCONSIN

89 WYOMING

Locality codes = 0, A1, A2, A3, A4, A5, A6, A7, B1, B2, B4, B5, B6, B7, B8, C1, C2, C3, C5, C7, C8, D2, D5,

D6, D8, E1, E3, E5, E7, F2, F6, F7, F8, G1, G2, G3, G5, G6, G7, G8, G9, H4, H5, H8, H9, J2, J3, J4, J6, J7,

and K4.

COMMENT: Carrier pricing locality isn’t maintained by CWF and CMS. Each MAC sets up their locality values that

would be sent to CWF.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 42

CARR_LINE_PRVDR_TYPE_CD

LABEL: Carrier Line Provider Type Code

DESCRIPTION: Code identifying the type of provider furnishing the service for this line item on the carrier claim.

SHORT NAME: PRV_TYPE

LONG NAME: CARR_LINE_PRVDR_TYPE_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: For Physician/Supplier Claims:

0 = Clinics, groups, associations,

partnerships, or other entities

1 = Physicians or suppliers reporting as

solo practitioners

2 = Suppliers (other than sole

proprietorship)

3 = Institutional provider

4 = Independent laboratories

5 = Clinics (multiple specialties)

6 = Groups (single specialty)

7 = Other entities

COMMENT: Prior to version H, DME claims also used this code; the following were valid codes:

0 = Clinics, groups, associations,

partnerships, or other entities for

whom the carrier's own ID number

has been assigned

1 = Physicians or suppliers billing as solo

practitioners for whom SSN's are

shown in the physician ID code field

2 = Physicians or suppliers billing as solo

practitioners for whom the carrier's

own physician ID code is shown

3 = Suppliers (other than sole

proprietorship) for whom EI

numbers are used in coding the ID

field

4 = Suppliers (other than sole proprietorship)

for whom the carrier's own code has

been shown

5 = Institutional providers and independent

laboratories for whom EI numbers are

used in coding the ID field

6 = Institutional providers and independent

laboratories for whom the carrier's own

ID number is shown

7 = Clinics, groups, associations, or

partnerships for whom EI numbers are

used in coding the ID field

8 = Other entities for whom EI numbers are

used in coding the ID field or

proprietorship for whom EI numbers are

used in coding the ID field

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 43

CARR_LINE_RDCD_PMT_PHYS_ASTN_C

LABEL: Carrier Line Reduced Payment Physician Assistant Code

DESCRIPTION: The code on the carrier (non-DMERC) line item that identifies the line items that have been paid a

reduced fee schedule amount (65%, 75%, or 85%) because a physician's assistant performed the

service.

SHORT NAME: ASTNT_CD

LONG NAME: CARR_LINE_RDCD_PMT_PHYS_ASTN_C

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: BLANK = Adjustment situation (where CLM_DISP_CD equal 3)

0 = N/A

1 = 65% of payment. Either physician assistants assisting in surgery or nurse midwives

2 = 75% of payment. Either physician assistants performing services in a hospital (other than assisting

surgery) or nurse practitioners/clinical nurse specialist performing services in rural areas or clinical

social worker services

3 = 85% of payment. Either physician assistant services for other than assisting surgery or other

hospital services or nurse practitioners’ services (not in rural areas)

COMMENT: —

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 44

CARR_LINE_RX_NUM

LABEL: Carrier Line RX Number

DESCRIPTION: The number used to identify the prescription order number for drugs and biologicals purchased

through the competitive acquisition program (CAP).

SHORT NAME: CARRXNUM

LONG NAME: CARR_LINE_RX_NUM

TYPE: CHAR

LENGTH: 30

SOURCE: NCH

VALUES: —

COMMENT: The prescription order number consists of:

• Vendor ID number (positions 1–4)

• HCPCS code (positions 5–9)

• Vendor controlled prescription number (positions 10–30)

The Medicare Modernization Act (MMA) required CMS to implement at a competitive acquisition

program (CAP) for Part B drugs and biologicals not paid on a cost or PPS basis. Physicians have a choice

between buying and billing these drugs under the average sales price (ASP) or obtaining these drugs

from an approved CAP vendor. The prescription number is needed to identify which claims were

submitted for CAP drugs and their administration.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 45

CARR_NUM

LABEL: Carrier or MAC Number

DESCRIPTION: The identification number assigned by CMS to a carrier authorized to process claims from a physician

or supplier.

Effective July 2006, the Medicare Administrative Contractors (MACs) began replacing the existing

carriers and started processing physician or supplier claim records for states assigned to its

jurisdiction.

SHORT NAME: CARR_NUM

LONG NAME: CARR_NUM

TYPE: CHAR

LENGTH: 5

SOURCE: NCH

VALUES: 00510 = Alabama — CAHABA (eff. 1983; term. 05/2009)

00511 = Georgia — CAHABA (eff. 1998; term. 06/2009) (replaced by MAC #10202)

00512 = Mississippi — CAHABA (eff. 2000)

00520 = Arkansas BC/BS (eff. 1983)

00521 = New Mexico — Arkansas BC/BS (eff. 1998; term. 02/2008) (replaced by MAC #04202)

00522 = Oklahoma — Arkansas BC/BS (eff. 1998; term. 02/2008) (replaced by MAC #04302)

00523 = Missouri East — Arkansas BC/BS (eff. 1999; term. 02/2008) (replaced by MAC #05392)

00524 = Rhode Island — Arkansas BC/BS (eff. 2004; term. 01/2009) (replaced by MAC #14402)

00528 = Louisiana — Arkansas BS (eff. 1984)

00542 = California BS (eff. 1983; term. 05/2009)

00590 = Florida — First Coast (eff. 1983; term. 01/2009) (replaced by MAC #09102)

00591 = Connecticut — First Coast (eff. 2000; term. 07/2008) (replaced by MAC #13102)

00630 = Indiana — Administer (eff. 1983) (term. 08/2012) (replaced by MAC #08102)

00635 = DMERC-B — Administer (eff. 1993; term. 06/2006) (replaced by MAC #17003)

00650 = Kansas BCBS (eff. 1983; term. 02/2008) (replaced by MAC #05202)

00651 = Missouri — Kansas BCBS (eff. 1983; term. 02/2008) (replaced by MAC #05202)

00655 = Nebraska — Kansas BC/BS (eff. 1988; term. 02/2008) (replaced by MAC #05402)

00660 = Kentucky — Administer (eff. 1983; term. 04/2011)

00663 = FQHC Pilot Demo (CAFM — Ayers-Ramsey) (term. 11/2011)

00710 = Michigan BS (eff. 1983; term. 09/2000)

00720 = Minnesota BS (eff. 1983; term. 09/2000)

00740 = Western Missouri — Kansas BS (eff. 1983; term. 06/1997) (replaced by MAC #05302)

00751 = Montana BC/BS (eff. 1983; term. 11/2006) (replaced by MAC # 03202)

00801 = New York — Health now (eff. 1983; term. 08/2008) (replaced by MAC #13282)

00803 = New York — Empire BS (eff. 1983; term. 07/2008) (replaced by MAC #13202)

00804 = New York — Rochester BS (term. 02/1999) (replaced by MAC # 12402)

00805 = New Jersey — Empire BS (eff. 3/99; term. 11/2008) (replaced by MAC # 12402)

00811 = DMERC (A) — Health now (eff. 2000; term. 06/2006) (replaced by MAC #16003)

00820 = North Dakota — Noridian (eff. 1983; term. 11/2006) (replaced by MAC #03302)

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 46

00823 = Utah — Noridian (eff. 12/1/2005; term. 11/2006) (replaced by MAC #03502)

00824 = Colorado — Noridian (eff. 1995; term. 02/2008) (replaced by MAC #04102)

00825 = Wyoming — Noridian (eff. 1990; term. 11/2006) (replaced by MAC #03602)

00826 = Iowa — Noridian (eff. 1999; term. 01/2008) (replaced by MAC #05102)

00831 = Alaska — Noridian (eff. 1998)

00832 = Arizona — Noridian (eff. 1998; term. 11/2006) (replaced by MAC # 03102)

00833 = Hawaii — Noridian (eff. 1998; term. 07/2008) (replaced by MAC # 01202)

00834 = Nevada — Noridian (eff. 1998; term. 07/2008) (replaced by MAC # 01302)

00835 = Oregon — Noridian (eff. 1998)

00836 = Washington — Noridian (eff. 1998)

00865 = Pennsylvania — Highmark (eff. 1983; term. 12/2008) (replaced by MAC # 12502)

00870 = Rhode Island BS (eff. 1983; term. 02/1999)

00880 = South Carolina — Palmetto (eff. 1983; term. 06/2011)

00882 = RRB — South Carolina PGBA (eff. 2000)

00883 = Ohio — Palmetto (eff. 2002; term. 06/2011)

00884 = West Virginia — Palmetto (eff. 2002; term. 06/2011)

00885 = DMERC C — Palmetto (eff. 1993; term. 05/2006) (replaced by MAC #18003)

00889 = South Dakota — Noridian (eff. 4/1/2006; term. 11/2006) (replaced by MAC # 03402)

00900 = Texas — Trailblazer (eff. 1983; term. 06/2008) (replaced by MAC # 04402)

00901 = Maryland — Trailblazer (eff. 1995; term. 07/2008) (replaced by MAC # 12302)

00902 = Delaware — Trailblazer (eff. 1998; term. 07/2008) (replaced by MAC # 12102)

00903 = District of Columbia — Trailblazer (eff. 1998; term. 07/2008) (replaced by MAC # 12202)

00904 = Virginia — Trailblazer (eff. 2000; term. 03/2011) (replaced by MAC # 11302)

00910 = Utah BS (eff. 1983; term. 09/2006)

00951 = Wisconsin — Wisconsin Phy Svc (eff. 1983)

00952 = Illinois — Wisconsin Phy Svc (eff. 1999)

00953 = Michigan — Wisconsin Phy Svc (eff. 1999; term. 07/15/2012) (replaced by MAC #08202)

00954 = Minnesota — Wisconsin Phy Svc (eff. 2000)

00960 = WPS Part D GAP (CAFM) (Truffer) (eff. 01/2010)

00973 = Puerto Rico — Triple S, Inc. (eff. 1983; term. 02/2009) (replaced by MAC # 09302)

00974 = Triple-S, Inc. — Virgin Islands (term. 02/2009)

01002 = J1 Roll-up

01102 = California (eff. 9/1/08) (replaces carrier #00832)

1112 = California, Northern — Noridian Healthcare Solutions

11182 = California, Southern — Noridian Healthcare Solutions

01192 = Palmetto GBA J1 (S CA) (eff. 09/2001/2008)

01202 = Hawaii (eff. 8/1/08) (replaces carrier #00833)

1212 = American Samoa. Guam, Hawaii, Northern Mariana Islands — Noridian Healthcare Solutions

01302 = Nevada (eff. 8/1/08) (replaces carrier #00834)

1312 = Nevada — Noridian Healthcare Solutions

01380 = Oregon — AETNA (eff. 1983; term. 09/2000)

01390 = Washington — AETNA (eff. 1994; term. 09/2000)

02002 = JF Roll-up (2/3)

02050 = California — TOLIC (eff. 1983; term. 09/1991)

02102 = Alaska — Noridian Admin Svcs (eff. 02/2001/2012)

02202 = Idaho — Noridian Admin Svcs (eff. 02/2001/2012)

02302 = Oregon — Noridian Admin Svcs (eff. 02/2001/2012)

02402 = Washington — Noridian Admin Svcs (eff. 02/2001/2012)

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 47

02831 = WEST.CONSORT.OCCIDENTAL — ALASKA (term. 07/2002)

02832 = WEST.CONSORT.OCCIDENTAL — ALASKA (term. 07/2002)

02833 = WEST.CONSORT.OCCIDENTAL — ALASKA

02835 = WEST.CONSORT.OCCIDENTAL — ALASKA

03002 = JF Roll-up (2/3) (orig. J3)

03102 = Arizona (eff. 12/1/2006) (replaces carrier #00832)

03202 = Montana (eff. 12/1/2006) (replaces carrier #00751)

03302 = N. Dakota (eff. 12/1/2006) (replaces carrier #00820)

03402 = S. Dakota (eff. 12/1/2006) (replaces carrier #00889)

03502 = Utah (eff. 12/1/2006) (replaces carrier #00823)

03602 = Wyoming (eff. 12/1/2006) (replaces carrier #00825)

04002 = J4 Roll-up

04102 = Colorado (eff. 3/24/08; term.) (replaces carrier #00550)

04112 = Colorado — Novitas Solutions JH (eff. 11/17/2012)

04202 = New Mexico (eff. 3/1/08 (replaces carrier #00521)

04212 = New Mexico — Novitas Solutions JH (eff. 11/17/2012)

04302 = Oklahoma (eff. 3/1/08) (replaces carrier #00522)

04312 = Oklahoma — Novitas Solutions JH (eff. 11/17/2012)

04402 = Texas (eff. 6/2001/08) (replaces carrier #00900)

04412 = Texas — Novitas Solutions JH (eff. 11/17/2012)

05002 = J5 Roll-up

05102 = Iowa (eff.2/1/08) (replaces carrier #00826)

05130 = Idaho — CIGNA (eff. 1983)

05202 = Kansas (eff. 3/1/08) (replaces carrier #00650)

05302 = W. Missouri (eff. 3/1/08) (replaces carrier #00651 or 00740)

05330 = NEW YORK — Equitable

05392 = E. Missouri (eff. 6/1/08) (replaces carrier #00523)

05402 = Nebraska (eff. 3/1/08) (replaces carrier #00655)

05440 = Tennessee — CIGNA (eff. 1983; term. 08/2009) (replaced by MAC #10302)

05535 = North Carolina — CIGNA (eff. 1988)

05655 = DMERC-D Alaska — CIGNA (eff. 1993; term. 09/2006) (replaced by MAC #19003)

06002 = J6 Roll-up

06102 = Illinois

06140 = Illinois — Continental Casualty (term. 11/2008)

06202 = Minnesota

06302 = Wisconsin

07002 = JH Roll-up (4/7)

07102 = Arkansas — Novitas Solutions JH (eff. 08/11/2012) (CR7812)

07180 = Kentucky — Metropolitan (term. 11/2000)

07202 = Louisiana — Novitas Solutions JH (eff. 08/11/2012)

07302 = Mississippi — Novitas Solutions JH (eff. 10/20/2012)

08002 = J8 Roll-up

08102 = Indiana (eff. 8/20/2012) (replaces carrier #00630)

08190 = Louisiana — Pan American10070 = RRB — UnitedHealthcare (term. 02/2004)

08202 = Michigan (eff. 7/16/2012) (replaces carrier #00953)

09002 = J9 Roll-up

09102 = Florida — First Coast (eff. 02/2009) (replaces carrier #00590)

09202 = Puerto Rico — First Coast (eff. 03/2009) (replaces carrier #00973)

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09302 = Virgin Island — First Coast (eff. 03/2009) (replaces carrier #00974)

10002 = J10 Roll-up

10071 = RRB — United Healthcare (term. 2000)

10072 = RRB — United Healthcare (term.)

10074 = RRB — United Healthcare (term. 09/2000)

10102 = Alabama (eff. 5/4/09) (replaces carrier #00510)

10112 =Alabama, statewide, all counties — Palmetto GBA

10202 = Georgia (eff. 8/3/09) (replaces carrier #00511)

10212 = Georgia, Atlanta and rest of state — Palmetto GBA

10230 = Connecticut — Metra Health (eff. 1986; term. 2000)

10240 = Minnesota — Metra Health (eff. 1983; term. 08/1994)

10250 = Mississippi — Metra Health (eff. 1983; term. 09/2000)

10302 = Tennessee (eff. 9/1/09) (replaces carrier #05440)

10312 = Tennessee, statewide, all counties — Palmetto GBA

10490 = Virginia — Metra Health (eff. 1983; term. 05/1997)

10555 = DMERC A — United Healthcare (eff. 1993; term. 12/1993)

11002 = J11 Roll-up

11202 = South Carolina — Palmetto Gov. Benefits Admin. (PGBA)

11302 = Virginia (eff. 3/19/2011) Palmetto Gov. Benefits Admin. (PGBA) (replaces carrier #00904)

11402 = West Virginia (eff. 6/18/2011) Palmetto Gov. Benefits Admin. (PGBA)

11502 = North Carolina (eff. 5/28/2011) Palmetto Gov. Benefits Admin. (PGBA)

12002 = J12 Roll-up

12102 = Delaware (eff. 7/11/2008) (replaces carrier #00902)

12202 = District of Columbia (eff. 7/11/2008) (replaces carrier #00903) NOTE: Includes Montgomery &

Prince Georges Counties in Maryland; and Fairfax County and the City of Alexandria, VA

12302 = Maryland (eff. 7/11/2008) (replaces carrier #00901)

12402 = New Jersey (eff. 11/14/2008) (replaces carrier #00805)

12502 = Pennsylvania (eff. 12/12/2008) (replaces carrier #00865)

13002 = J13 Roll-up

13102 = Connecticut (eff. 8/1/2008) (replaces carrier #00591)

13202 = East New York (eff. 7/18/2008) (replaces carrier #00803)

13282 = West New York (eff. 9/1/2008) (replaces carrier #00801)

13292 = New York (Queens) (eff. 7/18/2008) (replaces carrier #14330)

14002 = J14 Roll-up

14102 = Maine (eff. 6/1/2009) (replaces carrier #31142)

14112 = Maine, southern Maine and rest of state — National Government Services, Inc.

14202 = Massachusetts (eff. 6/1/2009) (replaces carrier #31143)

14212 = Massachusetts, metro Boston and rest of state — National Government Services, Inc.

14302 = N. Hampshire (eff. 6/1/2009) (replaces carrier #31144)

14312 = New Hampshire, statewide — National Government Services, Inc.

14330 = New York — GHI (eff. 1983; term. 07/2008) (replaced by MAC #13292)

14402 = Rhode Island (eff. 5/1/2009) (replaces carrier #00524)

14412 = Rhode Island, statewide — National Government Services, Inc.

14502 = Vermont (eff. 6/1/2009) (replaces carrier #31145)

14512 = Vermont, statewide — National Government Services, Inc.

15002 = J15 Roll-up

15102 = Kentucky (eff. 4/30/2011) CGS Government Services

15202 = Ohio (eff. 06/15/2011) CGS Government Services

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16003 = National Heritage Insurance Company (NHIC) (A) (eff. 7/1/2006) (replaces carrier #00811)

16013 = CT, DE, DC, ME, MD, MA, NH, NJ, NY, PA, RI, VT — Noridian Healthcare Solutions, LLC (DME

MAC)

16360 = Ohio — Nationwide Insurance Co. (eff. 1983; term. 2002)

16510 = West Virginia — Nationwide Insurance Co. (eff. 1983; term. 2002)

17003 = Administer Federal, Inc. (B) (eff. 7/1/2006) (replaces carrier #00635)

17013 = IL, IN, KY, MI, MN, OH, WI — CGS Administrators, LLC (DME MAC)

18003 = Connecticut General (CIGNA) (C) (eff. 06/2006) (replaces carrier #00885)

19003 = Noridian Mutual Ins. Co (D) (eff. 10/1/2006) (replaces carrier #05655)

31140 = North California — National Heritage Ins. (eff. 1997; term. 08/2008) (replaced by MAC

#01102)

31142 = Maine — National Heritage Ins. (eff. 1998; term. 05/2009) (replaced by MAC # 14102)

31143 = Massachusetts — National Heritage Ins. (eff. 1998; term. 05/2009) (replaced by MAC # 14202)

31144 = New Hampshire — National Heritage Ins. (eff. 1998; term. 05/2009) (replaced by MAC #

14302)

31145 = Vermont — National Heritage Ins. (eff. 1998; term. 05/2009)

31146 = South California — NHIC (eff. 2000; term. 08/2008)

66001 = Noridian Competitive Acquisition Program

80884 = Contractor ID for Physician Risk Adjustment Data (data not sent through NCH, but through

Palmetto)

COMMENT: Values and websites referenced may change over time. Refer to this website for current information:

https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-

are-the-MACs.

Prior to version H this field was named: FICARR_IDENT_NUM.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 50

CARR_PRFRNG_PIN_NUM

LABEL: Carrier Line Performing Provider ID Number (PIN)

DESCRIPTION: The provider identification number (PIN) of the physician/supplier (assigned by the Medicare

Administrative Contractor [MAC]) who performed the service for this line item.

SHORT NAME: PRF_PRFL

LONG NAME: CARR_PRFRNG_PIN_NUM

TYPE: CHAR

LENGTH: 15

SOURCE: NCH

VALUES: —

COMMENT: CMS identifies providers using the National Provider Identifier (NPI; eff. May 1, 2007), which replaces

legacy numbers (UPINs, PINs, etc.) on the standard HIPPA claim transactions.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 51

CLAIM_QUERY_CODE

LABEL: Claim Query Code

DESCRIPTION: Code indicating the type of claim record being processed with respect to payment (debit/credit

indicator; interim/final indicator).

SHORT NAME: QUERY_CD

LONG NAME: CLAIM_QUERY_CODE

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: 1 = Interim bill

3 = Final bill

5 = Debit adjustment

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 52

CLM_ADJUST_GRP_CD

LABEL: Claim Adjustment Group Code

DESCRIPTION: Claim adjustment group code used to categorize a payment adjustment for a claim or claim line. This

field is currently only populated for Direct Contracting (DC), Comprehensive Kidney Care Contracting

(CKCC) and Kidney Care First (KCF) model claims.

SHORT NAME: CLM_ADJUST_GRP_CD

LONG NAME: CLM_ADJUST_GRP_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES: CO = Contractual obligation

OA = Other adjustment

PR = Patient responsibility

COMMENT: This code set is an external code set maintained by X12 (www.x12.org/codes). This field is not

populated prior to 2021.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 53

CLM_ADJUST_RSN_CD

LABEL: Claim Adjustment Reason Code

DESCRIPTION: Claim Adjustment Reason Code used to describe why a claim or claim line was paid differently than

billed. This field is currently only populated for Direct Contracting (DC), Comprehensive Kidney Care

Contracting (CKCC) and Kidney Care First (KCF) model claims.

SHORT NAME: CLM_ADJUST_RSN_CD

LONG NAME: CLM_ADJUST_RSN_CD

TYPE: CHAR

LENGTH: 5

SOURCE: NCH

VALUES: This is not a comprehensive list of values; refer to website below for current values and descriptions:

96 = Non-covered charge(s). At least one Remark Code must be provided

119 = Benefit maximum for this time period or occurrence has been reached

B9 = Patient is enrolled in a hospice

COMMENT: This code set is an external code set maintained by X12 (www.x12.org/codes). This field is not

populated prior to 2021.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 54

CLM_ADMSN_DT

LABEL: Claim Admission Date

DESCRIPTION: On an institutional claim, the date the beneficiary was admitted to the hospital, skilled nursing facility,

or religious non-medical health care institution, and starting October 2023 this field is added to reflect

the admission date for hospice or to a home health agency (HHA).

SHORT NAME: ADMSN_DT (in the inpatient and SNF files)

HHSTRTDT (in the HHA file)

CLM_ADMSN_DT (in the hospice files)

LONG NAME: CLM_ADMSN_DT

TYPE: DATE

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: The admission date is a required field on inpatient and HHA claims. The Medicare rule is the admission

date and the claim “from date” (field called CLM_FROM_DT) must be the same.

From 1/1/2020 until 10/2/2023, there was no direct way to determine the admission date for HHA.

Prior to January 2020, when this variable appeared in the HHA it is the date the care began for the

HHA services reported on the claim.

The date in this variable may precede the claim from date (CLM_FROM_DT) if this claim is for a

beneficiary who has been continuously under care.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 55

CLM_BASE_OPRTG_DRG_AMT

LABEL: Claim Base Operating DRG Amount

DESCRIPTION: The amount of the wage adjusted DRG operating payment plus the technology add-on payment.

SHORT NAME: CLM_BASE_OPRTG_DRG_AMT

LONG NAME: CLM_BASE_OPRTG_DRG_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: This variable was new in 2011.

It is populated only for inpatient claims.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 56

CLM_BENE_ID_TYPE_CD

LABEL: Claim Beneficiary Identifier Type Code

DESCRIPTION: This field identifies whether the claim was submitted by the provider, during the transition period,

with a HICN or MBI (for CMS internal use).

SHORT NAME: CLM_BENE_ID_TYPE_CD

LONG NAME: CLM_BENE_ID_TYPE_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: M = MBI

H = HICN

Null/missing

COMMENT: This field is populated for CMS internal use. It was new in 2017.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 57

CLM_BENE_PD_AMT

LABEL: Carrier Claim Beneficiary Paid Amount

DESCRIPTION: The amount paid by the beneficiary for the non-institutional Part B (carrier, or DMERC) claim.

SHORT NAME: CLM_BENE_PD_AMT

LONG NAME: CLM_BENE_PD_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 58

CLM_BNDLD_ADJSTMT_PMT_AMT

LABEL: Claim Bundled Adjustment Payment Amount

DESCRIPTION: This field represents the amount the claim was reduced for those hospitals participating in Model 1 of

the Bundled Payments for Care Improvement initiative (BPCI, Model 1).

SHORT NAME: CLM_BNDLD_ADJSTMT_PMT_AMT

LONG NAME: CLM_BNDLD_ADJSTMT_PMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: The hospital must be participating in the Model 1 of the Bundled Payments for Care Improvement

initiative (refer to CLM_CARE_IMPRVMT_MODEL_CD1). The percentage of the discount that this

amount represents is in the field called CLM_BNDLD_MODEL_1_DSCNT_PCT.

This field was new in 2013 and is null/missing for all previous years.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 59

CLM_BNDLD_MODEL_1_DSCNT_PCT

LABEL: Claim Bundled Model 1 Discount Percent

DESCRIPTION: This field identifies the discount percentage which will be applied to payment for all participating

hospitals' DRG over the lifetime of the Bundled Payments for Care Improvement initiative (BPCI,

Model 1).

SHORT NAME: CLM_BNDLD_MODEL_1_DSCNT_PCT

LONG NAME: CLM_BNDLD_MODEL_1_DSCNT_PCT

TYPE: NUM

LENGTH: 8

SOURCE: NCH

VALUES: X.XX

COMMENT: The hospital must be participating in the Model 1 of the BPCI (refer to

CLM_CARE_IMPRVMT_MODEL_CD1). The dollar amount of the payment reduction for the service is in

the field called CLM_BNDLD_ADJSTMT_PMT_AMT.

This field was new in 2013 and is null/missing for all previous years.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 60

CLM_CARE_IMPRVMT_MODEL_CD1

CLM_CARE_IMPRVMT_MODEL_CD2

CLM_CARE_IMPRVMT_MODEL_CD3

CLM_CARE_IMPRVMT_MODEL_CD4

LABEL: Claim Care Improvement Model Code (bundled payment)

DESCRIPTION: This code is used to identify the care improvement model being used for bundling payments. The

initiative if referred to as the Bundled Payments for Care Improvement initiative (BPCI).

SHORT NAME:

CLM_CARE_IMPRVMT_MODEL_CD1

CLM_CARE_IMPRVMT_MODEL_CD2

CLM_CARE_IMPRVMT_MODEL_CD3

CLM_CARE_IMPRVMT_MODEL_CD4

LONG NAME:

CLM_CARE_IMPRVMT_MODEL_CD1

CLM_CARE_IMPRVMT_MODEL_CD2

CLM_CARE_IMPRVMT_MODEL_CD3

CLM_CARE_IMPRVMT_MODEL_CD4

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES: 61 = Care Improvement Model 1 is used

62 = Care Improvement Model 2 is used

63 = Care Improvement Model 3 is used

64 = Care Improvement Model 4 is used

Null/missing

COMMENT: There are 4 of these Care Improvement Model fields (CLM_CARE_IMPRVMT_MODEL_CD1–

CLM_CARE_IMPRVMT_MODEL_CD4).

This field was new in 2013 and is null/missing for all previous years.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 61

CLM_CLNCL_TRIL_NUM

LABEL: Clinical Trial Number

DESCRIPTION: The number used to identify all items and line-item services provided to a beneficiary during their

participation in a clinical trial.

SHORT NAME: CCLTRNUM (in the carrier and DME files)

CLM_CLNCL_TRIL_NUM (in the IP, SNF, HHA, hospice and HOP files)

LONG NAME: CLM_CLNCL_TRIL_NUM

TYPE: CHAR

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: CMS is requesting the clinical trial number be voluntarily reported. The number is assigned by the

National Library of Medicine (NLM) Clinical Trials Data Bank when a new study is registered.

This field was effective September 1, 2008, for carrier and DME claims. Starting October 2023, this

field is also available on institutional claims, i.e., inpatient, SNF, home health, hospice, and institutional

outpatient claims. For institutional claims, the clinical trial number is also populated in the claim value

amount field, when claim value code is equal to “D4.” CMS will continue to populate the clinical trial

number in the claim value amount field, as well as this new field.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 62

CLM_DISP_CD

LABEL: Claim Disposition Code

DESCRIPTION: Code indicating the disposition or outcome of the processing of the claim record.

In the source CMS National Claims History (NCH), claims are transactional records, and several

iterations of the claim may exist (e.g., original claim, an edited/updated version, which also cancels the

original claim, etc.).

The final reconciled version of the claim is contained in CCW-produced data files, unless otherwise

requested. For final claims (at least those that are final at the time of the data file), this value will

always be “01.”

SHORT NAME: DISP_CD

LONG NAME: CLM_DISP_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES: 01 = Debit accepted

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 63

CLM_DRG_CD

LABEL: Claim Diagnosis Related Group Code (or MS-DRG Code)

DESCRIPTION: The diagnostic related group to which a hospital claim belongs for prospective payment purposes.

SHORT NAME: DRG_CD

LONG NAME: CLM_DRG_CD

TYPE: CHAR

LENGTH: 4

SOURCE: NCH

VALUES: —

COMMENT: Starting in January 2021 with NCH version L, this field changed from three characters to four.

GROUPER is the software that determines the DRG from data elements reported by the hospital.

Once determined, the DRG code is one of the elements used to determine the price upon which to

base the reimbursement to the hospitals under prospective payment.

Nonpayment claims (zero reimbursement) may not have a DRG present.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 64

CLM_DRG_OUTLIER_STAY_CD

LABEL: Claim Diagnosis Related Group Outlier Stay Code

DESCRIPTION: On an institutional claim, the code that indicates the beneficiary stay under the prospective payment

system (PPS) which, although classified into a specific diagnosis related group, has an unusually long

length (day outlier) or exceptionally high cost (cost outlier).

SHORT NAME: OUTLR_CD

LONG NAME: CLM_DRG_OUTLIER_STAY_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: 0 = No outlier

1 = Day outlier (condition code 60)

2 = Cost outlier (condition code 61)

*** Non-PPS Only ***

6 = Valid diagnosis related groups (DRG) received from the intermediary

7 = CMS developed DRG

8 = CMS developed DRG using patient status code

9 = Not groupable

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 65

CLM_E_POA_IND_SW1

CLM_E_POA_IND_SW2

CLM_E_POA_IND_SW3

CLM_E_POA_IND_SW4

CLM_E_POA_IND_SW5

CLM_E_POA_IND_SW6

CLM_E_POA_IND_SW7

CLM_E_POA_IND_SW8

CLM_E_POA_IND_SW9

CLM_E_POA_IND_SW10

CLM_E_POA_IND_SW11

CLM_E_POA_IND_SW12

LABEL: Claim Diagnosis E Code Present on Admission (POA) Indicator Code

DESCRIPTION: The present on admission (POA) indicator code associated with the diagnosis E codes (principal and

secondary).

In response to the Deficit Reduction Act of 2005, CMS began to distinguish between hospitalization

diagnoses that occurred prior to versus during the admission. The objective was to eventually not pay

hospitals more if the patient acquired a condition (e.g., infection) during the admission. This present

on admission (POA) field is used to indicate whether the diagnosis was present on admission.

Medicare claims did not indicate whether a diagnosis was POA until 2011.

SHORT NAME:

CLM_E_POA_IND_SW1

CLM_E_POA_IND_SW2

CLM_E_POA_IND_SW3

CLM_E_POA_IND_SW4

CLM_E_POA_IND_SW5

CLM_E_POA_IND_SW6

CLM_E_POA_IND_SW7

CLM_E_POA_IND_SW8

CLM_E_POA_IND_SW9

CLM_E_POA_IND_SW10

CLM_E_POA_IND_SW11

CLM_E_POA_IND_SW12

LONG NAME:

CLM_E_POA_IND_SW1

CLM_E_POA_IND_SW2

CLM_E_POA_IND_SW3

CLM_E_POA_IND_SW4

CLM_E_POA_IND_SW5

CLM_E_POA_IND_SW6

CLM_E_POA_IND_SW7

CLM_E_POA_IND_SW8

CLM_E_POA_IND_SW9

CLM_E_POA_IND_SW10

CLM_E_POA_IND_SW11

CLM_E_POA_IND_SW12

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES:

Y = Diagnosis was present at the time of

admission (POA)

N = Diagnosis was not present at the time of

admission

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U = Documentation is insufficient to

determine if condition was present

on admission

W = Provider is unable to clinically

determine whether condition was

present on admission

X = Denotes the end of the POA

indicators in special data processing

situations that may be identified by

CMS in the future.

Z = Denotes the end of the POA indicators

1 = Unreported/not used — exempt from POA

reporting — this code is the equivalent code

of a blank, however, it was determined that

blanks were undesirable when submitting

the data

COMMENT: Medicare claims did not indicate whether a diagnosis was POA until 2011.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 67

CLM_FAC_TYPE_CD

LABEL: Claim Facility Type Code

DESCRIPTION: The type of facility.

SHORT NAME: FAC_TYPE

LONG NAME: CLM_FAC_TYPE_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: 1 = Hospital

2 = Skilled nursing facility (SNF)

3 = Home health agency (HHA)

4 = Religious Non-medical (hospital)

6 = Intermediate Care (IMC)

7 = Clinic services or hospital-based renal dialysis facility

8 = Ambulatory Surgery Center (ASC) or other special facility (e.g., hospice)

COMMENT: This field, in combination with the service classification type code (variable called

CLM_SRVC_CLSFCTN_TYPE_CD) indicates the “type of bill” for an institutional claim. Many different

types of services can be billed on a Part A or Part B institutional claim and knowing the type of bill

helps to distinguish them.

The type of bill is the concatenation of two variables:

Facility type (CLM_FAC_TYPE_CD)

Service classification type (CLM_SRVC_CLSFCTN_TYPE_CD).

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 68

CLM_FREQ_CD

LABEL: Claim Frequency Code

DESCRIPTION: The third digit of the type of bill (TOB3) submitted on an institutional claim record to indicate the

sequence of a claim in the beneficiary's current episode of care

SHORT NAME: FREQ_CD

LONG NAME: CLM_FREQ_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES:

0 = Non-payment/zero claims

1 = Admit thru discharge claim

2 = Interim — first claim

3 = Interim — continuing claim

4 = Interim — last claim

5 = Late charge(s) only claim

7 = Replacement of prior claim

8 = Void/cancel prior claim

9 = Final claim (for HH PPS = process as

a debit/credit to RAP claim)

G = Common Working File

(NCH) generated

adjustment claim

H = CMS generated adjustment claim

I = Misc. adjustment claim (e.g., initiated

by intermediary or QIO)

J = Other adjustment request

K = OIG Initiated Adjustment Claim

M = Medicare secondary payer (MSP)

adjustment

P = Adjustment required by QIO

Q = Claim Submitted for Reconsideration

Outside of Timely Limits

COMMENT: This field can be used in determining the “type of bill” for an institutional claim. Often type of bill

consists of a combination of two variables: the facility type code (variable called CLM_FAC_TYPE_CD)

and the service classification type code (CLM_SRVC_CLSFCTN_TYPE_CD). This variable serves as the

optional third component of bill type, and it is helpful for distinguishing between final, interim, or RAP

(request for anticipated payment) claims, which is particularly helpful if you receive claims that are not

“final action.”

Many different types of services can be billed on a Part A or Part B institutional claim and knowing the

type of bill helps to distinguish them. The type of bill is the concatenation of three variables: the

facility type (CLM_FAC_TYPE_CD), the service classification type code

(CLM_SRVC_CLSFCTN_TYPE_CD), and the claim frequency code (CLM_FREQ_CD).

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 69

CLM_FROM_DT

LABEL: Claim From Date

DESCRIPTION: The first day on the billing statement covering services rendered to the beneficiary (aka “Statement

Covers From Date”).

SHORT NAME: FROM_DT

LONG NAME: CLM_FROM_DT

TYPE: DATE

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: For home health prospective payment system (PPS) claims, the “from” date and the “thru” date on the

RAP (request for anticipated payment) initial claim must always match.

The "from" date on the claim may not always represent the first date of services, particularly for home

health or hospice care. To obtain the date corresponding with the onset of services (or admission

date) use the admission date from the claim (variable called CLM_ADMSN_DT for IP, SNF, and HH —

and variable called CLM_HOSPC_START_DT_ID for hospice claims).

For Part B non-institutional (carrier and DME) services, this variable corresponds with the earliest of

any of the line-item level dates (e.g., in the line file, it is the first CLM_FROM_DT for any line on the

claim). It is almost always the same as the CLM_THRU_DT; exception is for DME claims — where some

services are billed in advance.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 70

CLM_FULL_STD_PYMT_AMT

LABEL: Claim Full Standard Payment Amount

DESCRIPTION: This variable is the standard payment amount for long-term care hospitals (LTCH) under the Medicare

prospective payment system (PPS), which is based on the MS-LTC-DRG.

This amount does not include any applicable outlier payment amount.

SHORT NAME: CLM_FULL_STD_PYMT_AMT

LONG NAME: CLM_FULL_STD_PYMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: Applies only to inpatient (LTCH) claims. This field is new in October 2015.

For a LTCH PPS claim, only one of four fields will be populated (CLM_SITE_NTRL_PYMT_CST_AMT,

CLM_SITE_NTRL_PYMT_IPPS_AMT, CLM_FULL_STD_PYMT_AMT, or

CLM_SS_OUTLIER_STD_PYMT_AMT) as they are mutually exclusive (i.e., only one of the four fields will

have a non-zero value). The field with the non-zero value is included in the Claim Payment Amount

field.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 71

CLM_HHA_LUPA_IND_CD

LABEL: Claim HHA Low Utilization Payment Adjustment (LUPA) Indicator Code

DESCRIPTION: The code used to identify those home health PPS claims that have 4 visits or less in a 60-day episode.

If an HHA provides 4 visits or less, they will be reimbursed based on a national standardized per visit

rate instead of home health resource groups (HHRGs).

SHORT NAME: LUPAIND

LONG NAME: CLM_HHA_LUPA_IND_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: L = Low utilization payment adjustment (LUPA) claim

Blank = Not a LUPA claim; process using home health resource groups (HHRG)

COMMENT: Beginning 10/1/2000, this field was populated with data. Claims processed prior to 10/1/2000

contained spaces.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 72

CLM_HHA_RFRL_CD

LABEL: Claim HHA Referral Code

DESCRIPTION: Effective with version “I”, the code used to identify the means by which the beneficiary was referred

for home health services.

SHORT NAME: HHA_RFRL

LONG NAME: CLM_HHA_RFRL_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES:

1 = Physician referral — the patient

was admitted upon the

recommendation of a personal

physician

2 = Clinic referral — the patient was

admitted upon the

recommendation of this facility's

clinic physician

3 = HMO referral — the patient was

admitted upon the

recommendation of a health

maintenance organization (HMO)

physician

4 = Transfer from hospital — the

patient was admitted as an

inpatient transfer from an acute

care facility

5 = Transfer from a skilled nursing

facility (SNF) — the patient was

admitted as an inpatient transfer

from a SNF

6 = Transfer from another health care

facility — the patient was admitted

as a transfer from a health care

facility other than an acute care

facility or SNF

7 = Emergency room — the patient was

admitted upon the recommendation of

this facility's emergency room physician

8 = Court/law enforcement — the patient

was admitted upon the direction of a

court of law or upon the request of a

law enforcement agency's

representative

9 = Information not available — the means

the patient was admitted is not known

A = Transfer from a critical access hospital —

patient was admitted/referred to this

facility as a transfer from a critical

access hospital

B = Transfer from another HHA —

beneficiaries are permitted to transfer

from one HHA to another unrelated

HHA under HH PPS (eff.10/2000)

C = Readmission to same HHA — if a

beneficiary is discharged from an HHA

and then readmitted within the original

60-day episode, the original episode

must be closed early and a new one

created

D = Unknown/invalid code

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COMMENT: The use of this code will permit the agency to send a new RAP allowing all claims to be accepted by

Medicare. (eff. 10/2000)

Beginning October 1, 2000, this field was populated with data. Claims processed prior to October 1,

2000, contained spaces in this field.

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 74

CLM_HHA_TOT_VISIT_CNT

LABEL: Claim HHA Total Visit Count

DESCRIPTION: The count of the number of HHA visits as derived by CMS.

SHORT NAME: VISITCNT

LONG NAME: CLM_HHA_TOT_VISIT_CNT

TYPE: NUM

LENGTH: 3

SOURCE: NCH

VALUES: —

COMMENT: Derivation rule (units associated with revenue center codes 042X, 043X, 044X, 055X, 056X, 057X, 058X,

and 059X). Value 999 will be displayed if the sum of the revenue center unit count equals or exceeds

999.

Effective July 1 1999, all HHA claims received with service from dates July 1 1999, and after will be

processed as if the units field contains the 15-minute interval count; and each visit revenue code line

item will be counted as ONE visit. This field is calculated correctly; but those users who derive the

count themselves they will have to revise their routine. NO LONGER IS THE COUNT DERIVED BY

ADDING UP THE UNITS FIELDS ASSOCIATED WITH THE HHA VISIT REVENUE CODES.

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 75

CLM_HOSPC_START_DT_ID

LABEL: Claim Hospice Start Date

DESCRIPTION: The start date of the beneficiary’s hospice period of coverage. Applies only to institutional hospice

claims.

SHORT NAME: HSPCSTRT

LONG NAME: CLM_HOSPC_START_DT_ID

TYPE: DATE

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: This field is no longer populated. Starting in 2020, use the CLM_ADMSN_DT.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 76

CLM_HRR_ADJSTMT_PCT

LABEL: Claim HRR Adjustment Percent

DESCRIPTION: Under the Hospital Readmissions Reduction (HRR) Program, the amount used to identify the

readmission adjustment factor that will be applied.

SHORT NAME: CLM_HRR_ADJSTMT_PCT

LONG NAME: CLM_HRR_ADJSTMT_PCT

TYPE: NUM

LENGTH: 8

SOURCE: NCH

VALUES: X.XXXX

COMMENT: The ACA (Section 3025) requires CMS to reduce payments to subsection (d) inpatient prospective

payment system (IPPS) hospitals with excess readmissions. There is a variable that indicates whether

the hospital was excluded from the HRR program (reference CLM_HRR_PRTCPNT_IND_CD). This

percentage reduction is applied to the base operating DRG amount (defined as the wage adjusted DRG

payment plus new technology add-on payments).

Additional information is available on the CMS "Hospital Value-Based Purchasing" website.

The actual dollar amount of the adjustment that applied to the claim is found in the variable called

CLM_HRR_ADJSTMT_PMT_AMT.

This initiative began in fourth quarter of 2012 (e.g., beginning of federal fiscal year 13).

This field was new in 2012 and is null/missing for all previous years.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 77

CLM_HRR_ADJSTMT_PMT_AMT

LABEL: Claim Hospital Readmission Reduction (HRR) Adjustment Payment Amount

DESCRIPTION: This field represents the Hospital Readmission Reduction (HRR) Program Payment Amount. The

amount is the reduction to the claim for a readmission.

SHORT NAME: CLM_HRR_ADJSTMT_PMT_AMT

LONG NAME: CLM_HRR_ADJSTMT_PMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX (may be a negative value)

COMMENT: The ACA (Section 3025) requires CMS to reduce payments to subsection (d) inpatient prospective

payment system (IPPS) hospitals with excess readmissions. There is a variable that indicates whether

the hospital was excluded from the HRR program (reference CLM_HRR_PRTCPNT_IND_CD). This

percentage reduction is applied to the base operating DRG amount (defined as the wage adjusted DRG

payment plus new technology add-on payments).

Additional information is available on the CMS "Hospital Value-Based Purchasing" website.

This amount is based on a percent (CLM_HRR_ADJSTMT_PCT).

This initiative began in fourth quarter of 2012 (i.e., beginning of federal fiscal year 13).

This field was new in 2012 and is null/missing for all previous years.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 78

CLM_HRR_PRTCPNT_IND_CD

LABEL: Claim Hospital Readmission Reduction (HRR) Participant Indicator Code

DESCRIPTION: This field is the code used to identify whether the hospital is participating in the Hospital Readmissions

Reduction (HRR) program.

SHORT NAME: CLM_HRR_PRTCPNT_IND_CD

LONG NAME: CLM_HRR_PRTCPNT_IND_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: 0 = Not participating

1 = Participating and not equal to 1.0000

2 = Participating and equal to 1.0000

Null/missing = Not participating

COMMENT: The ACA (Section 3025) requires CMS to reduce payments to inpatient prospective payment system

(IPPS) hospitals with excess readmissions.

Additional information is available on the CMS "Hospital Value-Based Purchasing" website.

This initiative began in fourth quarter of 2012 (i.e., beginning of federal fiscal year 13).

This field was new in 2012 and is null/missing for all previous years.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 79

CLM_ID

LABEL: Claim ID

DESCRIPTION: This is the unique identification number for the claim.

Each Part A or institutional Part B claim has at least one revenue center record.

Each non-institutional Part B claim has at least one claim line.

All revenue center records or claim lines on a given claim have the same CLM_ID. It is used to link the

revenue lines together and/or to the base claim.

SHORT NAME: CLM_ID

LONG NAME: CLM_ID

TYPE: CHAR

LENGTH: 15

SOURCE: CCW

VALUES: —

COMMENT: The CLM_ID is assigned by the CCW. The CLM_ID is specific to the CCW and is not applicable to any

other identification system or data source.

Limitation: When pulled directly from the CCW database, this is a numeric column.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 80

CLM_IP_ADMSN_TYPE_CD

LABEL: Claim Inpatient Admission Type Code

DESCRIPTION: The code indicating the type and priority of an inpatient admission associated with the service on an

intermediary submitted claim.

SHORT NAME: TYPE_ADM

LONG NAME: CLM_IP_ADMSN_TYPE_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: 0 = Unknown Value (but present in data)

1 = Emergency — the patient required immediate medical intervention as a result of severe, life

threatening, or potentially disabling conditions. Generally, the patient was admitted through the

emergency room

2 = Urgent — the patient required immediate attention for the care and treatment of a physical or

mental disorder. Generally, the patient was admitted to the first available and suitable

accommodation

3 = Elective — the patient's condition permitted adequate time to schedule the availability of suitable

accommodations

4 = Newborn — necessitates the use of special source of admission codes.

5 = Trauma center — visits to a trauma center/hospital as licensed or designated by the state or local

government authority authorized to do so, or as verified by the American College of Surgeons and

involving a trauma activation

6 = Reserved

7 = Reserved

8 = Reserved

9 = Unknown — information not available

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 81

CLM_IP_INITL_MS_DRG_CD

LABEL: Claim Inpatient Initial MS DRG Code

DESCRIPTION: Claim inpatient Initial MS Diagnosis Related Group (DRG) Code

SHORT NAME: CLM_IP_INITL_MS_DRG_CD

LONG NAME: CLM_IP_INITL_MS_DRG_CD

TYPE: CHAR

LENGTH: 4

SOURCE: NCH

VALUES: XXXX

COMMENT: This field identifies the initial MS-DRG code assigned by MS-DRG Grouper prior to application of

Hospital Acquired Conditions (HAC) logic. The data will only be populated on inpatient claims.

Data will not start coming in until July 2019.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 82

CLM_IP_LOW_VOL_PMT_AMT

LABEL: Claim Inpatient Low Volume Payment Amount

DESCRIPTION: This is the amount field used to identify a payment adjustment given to hospitals to account for the

higher costs per discharge for low-income hospitals under the inpatient prospective payment system

(IPPS).

SHORT NAME: CLM_IP_LOW_VOL_PMT_AMT

LONG NAME: CLM_IP_LOW_VOL_PMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: Payment adjustment for low income IPPS hospitals.

This field was new in 2011.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 83

CLM_LINE_NUM

LABEL: Claim Line Number

DESCRIPTION: This variable identifies an individual line number on a claim.

Each revenue center record or claim line has a sequential line number to distinguish distinct services

that are submitted on the same claim.

All revenue center records or claim lines on a given claim have the same CLM_ID.

SHORT NAME: CLM_LN

LONG NAME: CLM_LINE_NUM

TYPE: NUM

LENGTH: 13

SOURCE: CCW

VALUES: —

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 84

CLM_MCO_PD_SW

LABEL: Claim MCO Paid Switch

DESCRIPTION: A switch indicating whether or not a Managed Care Organization (MCO) has paid the provider for an

institutional claim.

SHORT NAME: MCOPDSW

LONG NAME: CLM_MCO_PD_SW

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: Blank = No managed care organization (MCO) payment

0 = No managed care organization (MCO) payment

1 = MCO paid provider for the claim

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 85

CLM_MDCL_REC

LABEL: Claim Medical Record Number

DESCRIPTION: The number assigned by the provider to the beneficiary's medical record to assist in record retrieval.

SHORT NAME: CLM_MDCL_REC

LONG NAME: CLM_MDCL_REC

TYPE: CHAR

LENGTH: 17

SOURCE: NCH

VALUES: —

COMMENT: This variable may be null/missing.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 86

CLM_MDCR_NON_PMT_RSN_CD

LABEL: Claim Medicare Non-Payment Reason Code

DESCRIPTION: The reason that no Medicare payment is made for services on an institutional claim.

SHORT NAME: NOPAY_CD

LONG NAME: CLM_MDCR_NON_PMT_RSN_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES:

A = Covered worker's compensation

(Obsolete)

B = Benefit exhausted

C = Custodial care — non-covered care

(includes all “beneficiary at fault”

waiver cases) (Obsolete)

E = HMO out-of-plan services not

emergency or urgently needed

(Obsolete)

E = MSP cost avoided — IRS/SSA/HCFA

Data Match (eff. 7/2000)

F = MSP cost avoids HMO Rate Cell

(eff. 7/2000)

G = MSP cost avoided Litigation

Settlement (eff. 7/2000)

H = MSP cost avoided Employer

Voluntary Reporting (eff. 7/2000)

J = MSP cost avoids Insurer Voluntary

Reporting (eff. 7/2000)

K = MSP cost avoids Initial Enrollment

Questionnaire (eff. 7/2000)

N = All other reasons for non-payment

P = Payment requested

Q = MSP cost avoided Voluntary Agreement

(eff. 7/2000)

R = Benefits refused, or evidence not

submitted

T = MSP cost avoided — IEQ contractor (eff.

9/1976) (obsolete 6/30/2000)

U = MSP cost avoided — HMO rate cell

adjustment (eff. 9/1976) (Obsolete

6/30/2000)

V = MSP cost avoided — litigation settlement

(eff. 9/1976) (Obsolete 6/30/2000)

W = Worker's compensation (Obsolete)

X = MSP cost avoided — generic

Y = MSP cost avoided — IRS/SSA data match

project (obsolete 6/30/2000)

Z = Zero reimbursement RAPs — zero

reimbursement made due to medical

review intervention or where provider

specific zero payment has been

determined. (eff. with HHPPS —

10/2000)

00 = MSP cost avoided — COB Contractor

12 = MSP cost avoided — BCBS Voluntary

Agreements

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13 = MSP cost avoided — Office of

Personnel Management

14 = MSP cost avoided — Workman's

Compensation (WC) Datamatch

15 = MSP cost avoided — Workman's

Compensation Insurer Voluntary

Data Sharing Agreements (WC

VDSA) (eff. 4/2006)

16 = MSP cost avoided — Liability

Insurer VDSA (eff. 4/2006)

17 = MSP cost avoided — No-Fault

Insurer VDSA (eff. 4/2006)

18 = MSP cost avoided — Pharmacy

Benefit Manager Data Sharing

Agreement (eff. 4/2006)

19 = REFERENCE NOTE4: Coordination

of Benefits Contractor 11119

(reference CMS Change Request

7906 for identification of the

contractor.)

21 = MSP cost avoided — MIR Group Health

Plan (eff. 1/2009)

22 = MSP cost avoided — MIR non-Group

Health Plan (eff. 1/2009)

25 = MSP cost avoided — Recovery Audit

Contractor — California (eff. 10/2005)

26 = MSP cost avoided — Recovery Audit

Contractor — Florida (eff. 10/2005)

42 = REFERENCE NOTE4: Coordination of

Benefits Contractor 11142 (reference

CMS Change Request 7906 for

identification of the contractor.)

43 = REFERENCE NOTE4: Coordination of

Benefits Contractor 11143 (reference

CMS Change Request 7906 for

identification of the contractor.)

Effective 4/1/2002, the Medicare nonpayment reason code was expanded to a 2-byte field. The NCH

instituted a crosswalk from the 2-byte code to a 1-byte character code. Below are the character codes

(found in NCH and NMUD). At some point, NMUD will carry the 2-byte code but NCH will continue to

have the 1-byte character code.

! = MSP cost avoided — COB

Contractor (“00” 2-byte code)

@ = MSP cost avoided — BC/BS

Voluntary Agreements (“12” 2-

byte code)

# = MSP cost avoided — Office of

Personnel Management (“13” 2-

byte code)

$ = MSP cost avoided — Workman's

Compensation (WC) Datamatch

(“14” 2-byte code)

* =MSP cost avoided — Workman's Compensation

Insurer Voluntary Data Sharing Agreements (WC

VDSA) (“15” 2-byte code) (eff. 4/2006)

( = MSP cost avoided — Liability Insurer VDSA (“16”

2-byte code) (eff. 4/2006)

) = MSP cost avoided — No-Fault Insurer VDSA (“17”

2-byte code) (eff. 4/2006)

+ = MSP cost avoided — Pharmacy Benefit Manager

Data Sharing Agreement (“18” 2-byte code) (eff.

4/2006)

< = MSP cost avoided — MIR Group Health Plan

(“21” 2-byte code) (eff. 1/2009)

> = MSP cost avoided — MIR non-Group Health Plan

(“22” 2-byte code) (eff. 1/2009)

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% = MSP cost avoided — Recovery

Audit Contractor — California

(“25” 2-byte code) (eff.

10/2005)

& = MSP cost avoided — Recovery Audit Contractor

— Florida (“26” 2-byte code) (eff. 10/2005)

COMMENT: This field was put on all institutional claim types, but data did not start coming in on OP/HHA/hospice

until April 1, 2002. Prior to April 1, 2002, data only came in inpatient/SNF claims.

Effective April 1, 2002, this field was also expanded to two bytes to accommodate new values. The

NCH Nearline file did not expand the current one-byte field but instituted a crosswalk of the two-byte

field to the one-byte character value. Reference table of code for the crosswalk.

NOTE: Effective with version “J,” the field has been expanded on the NCH claim to two bytes. With this

expansion the NCH will no longer use the character values to represent the official two-byte values

being sent in by NCH since April 1, 2002.

During the version “J” conversion, all character values were converted to the two-byte values.

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 89

CLM_MODEL_4_READMSN_IND_CD

LABEL: Claim Model 4 Readmission Indicator Code

DESCRIPTION: This field identifies the method of payment of a claim billed within 30 days of a Model 4 Bundled

Payments for Care Improvement (BPCI) admission.

SHORT NAME: CLM_MODEL_4_READMSN_IND_CD

LONG NAME: CLM_MODEL_4_READMSN_IND_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: 1 = claim is related readmission to a Model 4 BPCI claim and shall pay IME, DSH, and capital only

2 = two Model 4 BPCI claims within 30 days of each other, first claim in episode shall process as it

would in the absence of Model 4 BPCI

3 = two Model 4 BPCI claims within 30 days of each other, this is the second claim in the episode and

paid as Model 4

Null/missing = not a BPCI claim

COMMENT: Bundling payment for services that patients receive across a single episode of care, such as heart

bypass surgery or a hip replacement, is one way to encourage doctors, hospitals, and other health care

providers to work together to better coordinate care for patients. Under the Model 4 BPCI pilot, CMS

will reimburse qualified acute care hospitals a blended payment for hospital inpatient care and

physician services connected with a single episode of care. This will occur in association with inpatient

hospital claims that the BPCI participating hospital will bill to their jurisdictional A/B MAC as type of bill

11X claims.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 90

CLM_MODEL_REIMBRSMT_AMT

LABEL: Claim Model Reimbursement Amount

DESCRIPTION: This field is used to identify the “net reimbursement amount” of what Medicare would have paid for

global budget services from a hospital participating in the particular model. If the claim only includes

global services, the reimbursement amount (CLM_PMT_AMT) will reflect $0. If the claim includes

global and non-global services, the reimbursement amount will reflect the amount Medicare actually

paid for the non-global services.

SHORT NAME: CLM_MODEL_REIMBRSMT_AMT

LONG NAME: CLM_MODEL_REIMBRSMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

COMMENT: This field is new in January 2020. This field only applies to Part A claims.

This model reimbursement amount applies to the Pennsylvania Rural Health Model (PARHM)

(CR11355). A demo code (variable called DEMO_ID_NUM) will be assigned for future models.

CLM_RLT_COND_CD = M6 (on the occurrence code file) and CLM_VAL_CD = Q4 (on the value code

file) have been created to identify the PARH model.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 91

CLM_NEXT_GNRTN_ACO_IND_CD1

CLM_NEXT_GNRTN_ACO_IND_CD2

CLM_NEXT_GNRTN_ACO_IND_CD3

CLM_NEXT_GNRTN_ACO_IND_CD4

CLM_NEXT_GNRTN_ACO_IND_CD5

LABEL: Claim Next Generation (NG) Accountable Care Organization (ACO) Indicator Code

DESCRIPTION: The field identifies the claims that qualify for specific claims processing edits related to benefit

enhancement through the Next Generation (NG) Accountable Care Organization (ACO).

SHORT NAME:

CLM_NEXT_GNRTN_ACO_IND_CD1

CLM_NEXT_GNRTN_ACO_IND_CD2

CLM_NEXT_GNRTN_ACO_IND_CD3

CLM_NEXT_GNRTN_ACO_IND_CD4

CLM_NEXT_GNRTN_ACO_IND_CD5

LONG NAME:

CLM_NEXT_GNRTN_ACO_IND_CD1

CLM_NEXT_GNRTN_ACO_IND_CD2

CLM_NEXT_GNRTN_ACO_IND_CD3

CLM_NEXT_GNRTN_ACO_IND_CD4

CLM_NEXT_GNRTN_ACO_IND_CD5

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: 0 = Base record (no enhancements)

1 = Population based payments (PBP)

2 = Telehealth

3 = Post discharge home health Visits

4 = 3-Day SNF waiver

5 = Capitation

6 = CEC telehealth

7 = Care management home visits

8 = Primary Care Capitation (PCC)

9 = Home health benefit enhancement — eff. 4/2021

A = Diabetic shoes – eff. 10/2023

B = Concurrent care for beneficiaries that elect the Medicare hospice benefit — eff. 4/2021

C = Kidney disease education (KDE) — eff. 4/2021

D = Seriously Ill population (SIP)

E = Flat visit fee (FVF)

F = Quarterly Capitation Payment (QCP) — eff. 4/2021

G = Performance based adjustment (PBA) — eff. 7/2022

H = Home infusion therapy – eff. 10/2023

I = Medical nutrition therapy – eff. 10/2023

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J = Hospice care – eff. 10/2023

K = Cardiac and pulmonary rehabilitation – eff. 10/2023

L = Making Care Primary (MCP) Benefit Enhancement Indicator Track 1

M = Making Care Primary (MCP) Benefit Enhancement Indicator Track 2

N = Making Care Primary (MCP) Benefit Enhancement Indicator Track 3

O = GUIDE Model Beneficiary covering all services

Z0 = PACE straddle claim

COMMENT: These fields were added to the DME claim lines October 2023. The Accountable Care Organization

(ACO) Realizing Equity, Access, and Community Health (REACH) Model made changes to expand

services to allow for nurse practitioners and physician assistants to certify, order and refer certain

Medicare services. Previously, these fields were on the carrier claims (on the line file) and on all

institutional claim types (inpatient, SNF, HHA, hospice, and outpatient) at the claim-level.

There are five occurrences of this field on a claim (or claim line), but each value can only be

represented once. The five occurrences of this field are found at the claim level on all institutional

claim types and at the line level on Part B carrier and DME claims.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 93

CLM_NON_UTLZTN_DAYS_CNT

LABEL: Claim Medicare Non-Utilization Days Count

DESCRIPTION: On an institutional claim, the number of days of care that are not chargeable to Medicare facility

utilization.

SHORT NAME: NUTILDAY

LONG NAME: CLM_NON_UTLZTN_DAYS_CNT

TYPE: NUM

LENGTH: 5

SOURCE: NCH

VALUES: —

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 94

CLM_OP_BENE_PMT_AMT

LABEL: Claim Outpatient Payment Amount to Beneficiary

DESCRIPTION: The amount paid, from the Medicare trust fund, to the beneficiary for the services reported on the

outpatient claim.

SHORT NAME: BENEPMT

LONG NAME: CLM_OP_BENE_PMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: —

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 95

CLM_OP_ESRD_MTHD_CD

LABEL: Claim Outpatient End-stage Renal Disease (ESRD) Method of Reimbursement Code

DESCRIPTION: This variable contains the code denoting the method of reimbursement selected by the beneficiary

receiving End-stage Renal Disease (ESRD) services for home dialysis (i.e., whether home supplies are

purchased through a facility or from a supplier.)

SHORT NAME: CLM_OP_ESRD_MTHD_CD

LONG NAME: CLM_OP_ESRD_MTHD_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: 0 = Not ESRD

1 = Method 1 — Home supplies purchased through a facility

2 = Method 2 — Home supplies purchased from a supplier

COMMENT: —

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 96

CLM_OP_PPS_IND

LABEL: Claim Outpatient prospective payment system (OPPS) Indicator

DESCRIPTION: The code indicating the type and priority of an inpatient admission associated with the service on an

intermediary submitted claim.

SHORT NAME: CLM_OP_PPS_IND

LONG NAME: CLM_OP_PPS_IND

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: 1 = OPPS

2 = Non-OPPS

COMMENT: A blank, zero or any other value is defaulted to 1. This field is not populated prior to 2021.

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 97

CLM_OP_PRVDR_PMT_AMT

LABEL: Claim Outpatient Provider Payment Amount

DESCRIPTION: The amount paid, from the Medicare trust fund, to the provider for the services reported on the

outpatient claim.

SHORT NAME: PRVDRPMT

LONG NAME: CLM_OP_PRVDR_PMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: —

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 98

CLM_OP_TRANS_TYPE_CD

LABEL: Claim Outpatient transaction type

DESCRIPTION: The code derived by CMS based on the type of bill and provider number to identify the outpatient

transaction type.

SHORT NAME: CLM_OP_TRANS_TYPE_CD

LONG NAME: CLM_OP_TRANS_TYPE_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES:

A = Outpatient Psychiatric hospital

B = Outpatient tuberculosis (TB)

hospital

C = Outpatient General Care hospital

D = Outpatient skilled nursing facility

(SNF)

E = Home health agency

F = Comprehensive Health Care

G = Clinical Rehab agency

H = Rural Health Clinic

I = Satellite Dialysis Facility

J = Limited Care Facility

0 = Christian Science SNF

1 = Psychiatric hospital Facility

2 = TB hospital Facility

3 = General Care hospital

4 = Regular SNF

Spaces = Home health/hospice

COMMENT: —

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 99

CLM_PASS_THRU_PER_DIEM_AMT

LABEL: Claim Pass Thru Per Diem Amount

DESCRIPTION: Medicare establishes a daily payment amount to reimburse IPPS hospitals for certain “pass-through”

expenses, such as capital-related costs, direct medical education costs, kidney acquisition costs for

hospitals that are renal transplant centers, and bad debts. This variable is the daily payment rate for

pass-through expenses. It is not included in the CLM_PMT_AMT field.

To determine the total of the pass-through payments for a hospitalization, this field should be

multiplied by the claim Medicare utilization day count (CLM_UTLZTN_DAY_CNT). Then, total Medicare

payments for a hospitalization claim can be determined by summing this product and the

CLM_PMT_AMT field.

SHORT NAME: PER_DIEM

LONG NAME: CLM_PASS_THRU_PER_DIEM_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: Medicare payments are described in detail in a series of Medicare Payment Advisory Commission

(MedPAC) documents called “Payment Basics” Reference: and also in the Medicare Learning Network

(MLN) “Payment System Fact Sheet Series” Reference the list of MLN publications at:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/html/medicare-payment-systems.html#Hospice

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 100

CLM_PMT_AMT

LABEL: Claim (Medicare) Payment Amount

DESCRIPTION: The Medicare claim payment amount.

For hospital services, this amount does not include the claim pass-through per diem payments made

by Medicare. To obtain the total amount paid by Medicare for the claim, the pass-through amount

(which is the daily per diem amount) must be multiplied by the number of Medicare-covered days

(e.g., multiply the CLM_PASS_THRU_PER_DIEM_AMT by the CLM_UTLZTN_DAY_CNT), and then added

to the claim payment amount (this field).

For non-hospital services (SNF, home health, hospice, and hospital outpatient) and for other non-

institutional services (carrier and DME), this variable equals the total actual Medicare payment

amount, and pass-through amounts do not apply.

For Part B non-institutional services (carrier and DME), this variable equals the sum of all the line item-

level Medicare payments (variable called the LINE_NCH_PMT_AMT).

SHORT NAME: PMT_AMT

LONG NAME: CLM_PMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: Medicare payments are described in detail in a series of Medicare Payment Advisory Commission

(MedPAC) documents called “Payment Basics” (reference: https://www.medpac.gov/document-

type/payment-basic/).

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (reference:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/html/medicare-payment-systems.html).

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 101

CLM_POA_IND_SW1

CLM_POA_IND_SW2

CLM_POA_IND_SW3

CLM_POA_IND_SW4

CLM_POA_IND_SW5

CLM_POA_IND_SW6

CLM_POA_IND_SW7

CLM_POA_IND_SW8

CLM_POA_IND_SW9

CLM_POA_IND_SW10

CLM_POA_IND_SW11

CLM_POA_IND_SW12

CLM_POA_IND_SW13

CLM_POA_IND_SW14

CLM_POA_IND_SW15

CLM_POA_IND_SW16

CLM_POA_IND_SW17

CLM_POA_IND_SW18

CLM_POA_IND_SW19

CLM_POA_IND_SW20

CLM_POA_IND_SW21

CLM_POA_IND_SW22

CLM_POA_IND_SW23

CLM_POA_IND_SW24

CLM_POA_IND_SW25

LABEL: Claim Diagnosis Code Present on Admission (POA) Indicator Code

DESCRIPTION: The present on admission (POA) indicator code associated with the diagnosis codes (principal and

secondary).

In response to the Deficit Reduction Act of 2005, CMS began to distinguish between hospitalization

diagnoses that occurred prior to versus during the admission. The objective was to eventually not pay

hospitals more if the patient acquired a condition (e.g., infection) during the admission.

This present on admission (POA) field is used to indicate whether the diagnosis was present on

admission.

Medicare claims did not indicate whether a diagnosis was POA until 2011.

SHORT NAME:

CLM_POA_IND_SW1

CLM_POA_IND_SW2

CLM_POA_IND_SW3

CLM_POA_IND_SW4

CLM_POA_IND_SW5

CLM_POA_IND_SW6

CLM_POA_IND_SW7

CLM_POA_IND_SW8

CLM_POA_IND_SW9

CLM_POA_IND_SW10

CLM_POA_IND_SW11

CLM_POA_IND_SW12

CLM_POA_IND_SW13

CLM_POA_IND_SW14

CLM_POA_IND_SW15

CLM_POA_IND_SW16

CLM_POA_IND_SW17

CLM_POA_IND_SW18

CLM_POA_IND_SW19

CLM_POA_IND_SW20

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 102

CLM_POA_IND_SW21

CLM_POA_IND_SW22

CLM_POA_IND_SW23

CLM_POA_IND_SW24

CLM_POA_IND_SW25

LONG NAME:

CLM_POA_IND_SW1

CLM_POA_IND_SW2

CLM_POA_IND_SW3

CLM_POA_IND_SW4

CLM_POA_IND_SW5

CLM_POA_IND_SW6

CLM_POA_IND_SW7

CLM_POA_IND_SW8

CLM_POA_IND_SW9

CLM_POA_IND_SW10

CLM_POA_IND_SW11

CLM_POA_IND_SW12

CLM_POA_IND_SW13

CLM_POA_IND_SW14

CLM_POA_IND_SW15

CLM_POA_IND_SW16

CLM_POA_IND_SW17

CLM_POA_IND_SW18

CLM_POA_IND_SW19

CLM_POA_IND_SW20

CLM_POA_IND_SW21

CLM_POA_IND_SW22

CLM_POA_IND_SW23

CLM_POA_IND_SW24

CLM_POA_IND_SW25

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: Y = Diagnosis was present at the time of admission (POA)

N = Diagnosis was not present at the time of admission

U = Documentation is insufficient to determine if condition was present on admission

W = Provider is unable to clinically determine whether condition was present on admission

1 = Unreported/not used — exempt from POA reporting — this code is the equivalent code of a blank,

however, it was determined that blanks were undesirable when submitting the data

Z = Denotes the end of the POA indicators

X = Denotes the end of the POA indicators in special data processing situations that may be identified

by CMS in the future

COMMENT: Prior to version “J,” the POA indicators were stored in a 10-byte field in the fixed portion of the claim.

The field was named: CLM_POA_IND_CD. Medicare claims did not indicate whether a diagnosis was

POA until 2011.

The present on admission indicators for the diagnosis E codes are stored in the present on admission

diagnosis E trailer.

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 103

CLM_PPS_CPTL_DRG_WT_NUM

LABEL: Claim PPS Capital DRG Weight Number

DESCRIPTION: The number used to determine a transfer adjusted case mix index for capital, under the prospective

payment system (PPS). The number is determined by multiplying the Diagnosis Related Group Code

(DRG) weight times the discharge fraction.

Medicare assigns a weight to each DRG to reflect the average cost of caring for patients with the DRG

compared to the average of all types of Medicare cases. This variable reflects the weight that is

applied to the base payment amount.

The DRG weights in this variable reflect adjustments due to patient characteristics and factors related

to the stay. For example, payments are reduced for certain short stay transfers or where patients are

discharged to post-acute care. Therefore, for a given DRG, the weight in this field may vary.

SHORT NAME: DRGWTAMT

LONG NAME: CLM_PPS_CPTL_DRG_WT_NUM

TYPE: NUM

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: Medicare payments are described in detail in a series of Medicare Payment Advisory Commission

(MedPAC) documents called “Payment Basics” (reference: https://www.medpac.gov/document-

type/payment-basic/)

Also, in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (reference:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/html/medicare-payment-systems.html).

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 104

CLM_PPS_CPTL_DSPRPRTNT_SHR_AMT

LABEL: Claim PPS Capital Disproportionate Share Amount

DESCRIPTION: The amount of disproportionate share (rate reflecting indigent population served) portion of the PPS

payment for capital.

This is one component of the total amount that is payable for capital PPS for the claim. The total

capital amount, which includes this variable, is in the variable CLM_TOT_PPS_CPTL_AMT.

SHORT NAME: DISP_SHR

LONG NAME: CLM_PPS_CPTL_DSPRPRTNT_SHR_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: Medicare payments are described in detail in a series of Medicare Payment Advisory Commission

(MedPAC) documents called “Payment Basics” (reference: https://www.medpac.gov/document-

type/payment-basic/).

Also, in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (reference:).

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 105

CLM_PPS_CPTL_EXCPTN_AMT

LABEL: Claim PPS Capital Exception Amount

DESCRIPTION: The capital PPS amount of exception payments provided for hospitals with inordinately high levels of

capital obligations. Exception payments expire at the end of the 10-year transition period.

This is one component of the total amount that is payable for capital PPS for the claim. The total

capital amount, which includes this variable, is in the variable CLM_TOT_PPS_CPTL_AMT.

SHORT NAME: CPTL_EXP

LONG NAME: CLM_PPS_CPTL_EXCPTN_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: Medicare payments are described in detail in a series of Medicare Payment Advisory Commission

(MedPAC) documents called “Payment Basics” (reference: https://www.medpac.gov/document-

type/payment-basic/)

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (reference:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/html/medicare-payment-systems.html).

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 106

CLM_PPS_CPTL_FSP_AMT

LABEL: Claim PPS Capital Federal Specific Portion (FSP) Amount

DESCRIPTION: The amount of the federal specific portion of the PPS payment for capital.

This is one component of the total amount that is payable for capital PPS for the claim. The total

capital amount, which includes this variable, is in the variable CLM_TOT_PPS_CPTL_AMT.

SHORT NAME: CPTL_FSP

LONG NAME: CLM_PPS_CPTL_FSP_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: Medicare payments are described in detail in a series of Medicare Payment Advisory Commission

(MedPAC) documents called “Payment Basics” (reference: https://www.medpac.gov/document-

type/payment-basic/)

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series”

(reference:https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/html/medicare-payment-systems.html).

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 107

CLM_PPS_CPTL_IME_AMT

LABEL: Claim PPS Capital Indirect Medical Education (IME) Amount

DESCRIPTION: The amount of the indirect medical education (IME) (reimbursable amount for teaching hospitals only;

an added amount passed by Congress to augment normal prospective payment system [PPS]

payments for teaching hospitals to compensate them for higher patient costs resulting from medical

education programs for interns and residents) portion of the PPS payment for capital.

This is one component of the total amount that is payable for capital PPS for the claim. The total

capital amount, which includes this variable, is in the variable CLM_TOT_PPS_CPTL_AMT.

SHORT NAME: IME_AMT

LONG NAME: CLM_PPS_CPTL_IME_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: Medicare payments are described in detail in a series of Medicare Payment Advisory Commission

(MedPAC) documents called “Payment Basics” (reference: https://www.medpac.gov/document-

type/payment-basic/).

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (reference:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/html/medicare-payment-systems.html).

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 108

CLM_PPS_CPTL_OUTLIER_AMT

LABEL: Claim PPS Capital Outlier Amount

DESCRIPTION: The amount of the outlier portion of the PPS payment for capital.

This is one component of the total amount that is payable for capital PPS for the claim. The total

capital amount, which includes this variable, is in the variable CLM_TOT_PPS_CPTL_AMT.

SHORT NAME: CPTLOUTL

LONG NAME: CLM_PPS_CPTL_OUTLIER_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: Medicare payments are described in detail in a series of Medicare Payment Advisory Commission

(MedPAC) documents called “Payment Basics” (reference: https://www.medpac.gov/document-

type/payment-basic/)

Also, in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (reference:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/html/medicare-payment-systems.html).

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 109

CLM_PPS_IND_CD

LABEL: Claim PPS Indicator Code

DESCRIPTION: The code indicating whether or not:

(1) the claim is from the prospective payment system (PPS), and/or

(2) the beneficiary is a deemed insured MQGE (Medicare Qualified Government Employee)

SHORT NAME: PPS_IND

LONG NAME: CLM_PPS_IND_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: Blank = Not a PPS bill

2 = PPS bill; claim contains PPS indicator

COMMENT: —

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 110

CLM_PPS_OLD_CPTL_HLD_HRMLS_AMT

LABEL: Claim PPS Old Capital Hold Harmless Amount

DESCRIPTION: This amount is the hold harmless amount payable for old capital as computed by PRICER for providers

with a payment code equal to “A”.

The hold harmless amount-old capital is 100 percent of the reasonable costs of old capital for sole

community hospitals, or 85 percent of the reasonable costs associated with old capital for all other

hospitals, plus a payment for new capital.

SHORT NAME: HLDHRMLS

LONG NAME: CLM_PPS_OLD_CPTL_HLD_HRMLS_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: This is one component of the total amount that is payable for capital PPS for the claim. The total

capital amount, which includes this variable, is in the variable CLM_TOT_PPS_CPTL_AMT.

Medicare payments are described in detail in a series of Medicare Payment Advisory Commission

(MedPAC) documents called “Payment Basics” (reference: https://www.medpac.gov/document-

type/payment-basic/).

Also, in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (reference:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/html/medicare-payment-systems.html).

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 111

CLM_PRCR_RTRN_CD

LABEL: Claim Pricer Return Code

DESCRIPTION: The code used to identify various prospective payment system (PPS) payment adjustment types. This

code identifies the payment return code or the error return code for every claim type calculated by

the PRICER tool.

SHORT NAME: CLM_PRCR_RTRN_CD

LONG NAME: CLM_PRCR_RTRN_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES: The meaning of the values varies by type of bill (TOB)

****Inpatient Hospital Pricer Return Codes******

******************TOB 11X***********************

Inpatient Hospital Payment return codes:

00 = Paid normal DRG payment

01 = Paid as a day outlier (NOTE: day

outlier no longer being paid as of

10/1/97)

02 = Paid as a cost outlier

03 = Transfer paid on a per diem basis

up to and including the full DRG

05 = Transfer paid on a per diem basis

up to and including the full DRG

which also qualified for a cost

outlier payment

06 = Provider refused cost outlier

10 = DRG is 209, 210, or 211 and post-

acute transfer

12 = Post-acute transfer with specific

DRGs. The following DRG's: 14, 113,

236, 263, 264, 429, 483

14 = Paid normal DRG payment with per

diem days = or > GM ALOS

16 = Paid as a cost outlier with per diem

days = or > GM ALOS

33 = For inpatient PPS, it means paid a per

diem payment to the transferring IPPS

hospital (when the patient transfers to

an IPPS hospital) up to and including

the full DRG payment if the covered

days are less than the geometric

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 112

Inpatient Hospital Error return codes:

51 = No provider specific information

found

52 = Invalid MSA# in provider file

53 = Waiver state — not

calculated by PPS

54 = DRG < 001 or > 511, or = 214, 215,

221, 222, 438, 456, 457, 458

55 = Discharge date < provider effective

start date or discharge date < MSA

effective start date for PPS

56 = Invalid length of stay

57 = Review code invalid (Not 00, 03, 06,

07, 09)

58 = Total charges not numeric

61 = Lifetime reserve days not numeric

or BILL-LTR-DAYS > 60

62 = Invalid number of covered days

65 = PAY-CODE not = A, B or C on

provider specific file for capital

67 = Cost outlier with LOS > covered days

***Inpatient Rehab Facility (IRF) Pricer Return Codes***

IRF Payment return codes:

00 = Paid normal CMG payment without

outlier

01 = Paid normal CMG payment with

outlier

02 = Transfer paid on a per diem basis

without outlier

03 = Transfer paid on a per diem basis

with outlier

04 = Blended CMG payment — 2/3

federal PPS rate + 1/3 provider

specific rate — without outlier

05 = Blended CMG payment — 2/3

federal PPS rate + 1/3 provider

specific rate — with outlier

06 = Blended transfer payment — 2/3

federal PPS transfer rate + 1/3

provider specific rate — without

outlier

07 = Blended transfer payment — 2/3

federal PPS transfer rate + 1/3

provider specific rate — with outlier

10 = Paid normal CMG payment with penalty without

outlier

11 = Paid normal CMG payment with penalty

with outlier

12 = Transfer paid on a per diem basis with

penalty without outlier

13 = Transfer paid on a per diem basis with

penalty with outlier

14 = Blended CMG payment — 2/3 federal PPS

rate + 1/3 provider specific rate — with

penalty without outlier

15 = Blended CMG payment — 2/3 federal PPS

rate + 1/3 provider specific rate — with

penalty with outlier

16 = Blended transfer payment — 2/3 federal

PPS transfer rate + 1/3 provider specific

rate — with penalty without outlier

17 = Blended transfer payment — 2/3 federal

PPS transfer rate + 1/3 provider specific

rate — with penalty with outlier

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IRF Error return codes:

50 = Provider specific rate not numeric

51 = Provider record terminated

52 = Invalid wage index

53 = Waiver state — not calculated by

PPS

54 = CMG on claim not found in table

55 = Discharge date < provider effective

start date or discharge date < MSA

effective start date for PPS

56 = Invalid length of stay

57 = Provider specific rate zero when

blended payment requested

58 = Total covered charges not numeric

59 = Provider specific record not found

60 = MSA wage index record not found

61 = Lifetime reserve days not numeric or

BILL-LTR-DAYS > 60

62 = Invalid number of covered days

65 = Operating cost-to-charge ratio not

numeric

67 = Cost outlier with LOS > covered days

or cost outlier threshold calculation

72 = Invalid blend indicator (not 3 or 4)

73 = Discharged before provider FY begin

date

74 = Provider FY begin date not in 2002

***Long-Term Care Hospital (LTCH) Pricer Return Codes***

LTCH Payment return codes:

00 = Normal DRG payment without

outlier

01 = Normal DRG payment with outlier

02 = Short stay payment without outlier

03 = Short stay payment with outlier

04 = Blend year 1 — 80% facility rate

plus 20% normal DRG payment

without outlier

05 = Blend year 1 — 80% facility rate

plus 20% normal DRG payment with

outlier

06 = Blend year 1 — 80% facility rate

plus 20% short stay payment

without outlier

07 = Blend year 1 — 80% facility rate

plus 20% short stay payment with

outlier

08 = Blend year 2 — 60% facility rate plus

40% normal DRG payment without

outlier

09 = Blend year 2 — 60% facility rate plus

40% normal DRG payment with outlier

10 = Blend year 2 — 60% facility rate plus

40% short stay payment without

outlier

11 = Blend year 2 — 60% facility rate plus

40% short stay payment with outlier

12 = Blend year 3 — 40% facility rate plus

60% normal DRG payment without

outlier

13 = Blend year 3 — 40% facility rate plus

60% normal DRG payment with outlier

14 = Blend year 3 — 40% facility rate plus

60% short stay payment without

outlier

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15 = Blend year 3 — 40% facility rate

plus 60% short stay payment

with outlier

16 = Blend year 4 — 20% facility rate

plus 80% normal DRG payment

without outlier

17 = Blend year 4 — 20% facility rate

plus 80% normal DRG payment

with outlier

18 = Blend year 4 — 20% facility rate

plus 80% short stay payment

without outlier

19 = Blend year 4 — 20% facility rate

plus 80% short stay payment with

outlier

20 = Short stay payment based on

estimated cost without outlier

21 = Short stay payment based on LTC-

DRG per diem without outlier

22 = For long-term care PPS, it means

short stay payment based on blend

of LTC-DRG PER DIEM and IPPS

comparable amount without outlier

23 = Short stay payment based on

estimated cost with outlier

24 = Short stay payment based on LTC-

DRG per diem with outlier

25 = Short stay payment based on blend

of LTC-DRG per diem and IPPS comp

amt with outlier

26 = For long-term care PPS, it means

short stay payment based on IPPS-

comparable threshold without

outlier

27 = Short stay payment based on IPPS

comparable threshold with outlier

28 = Subclause (II) without outlier

29 = Subclause (II) with outlier

LTCH Error return codes:

50 = Provider specific rate not

numeric

51 = Provider record terminated

52 = Invalid wage index

53 = Waiver state — not calculated

by PPS

54 = DRG on claim not found in

table

55 = Discharge date < provider

effective start date or discharge

date < MSA effective start date

for PPS

56 = Invalid length of stay

57 = Provider specific rate zero when

blended payment requested

58 = Total covered charges not numeric

59 = Provider specific record not found

60 = MSA wage index record not found

61 = Lifetime reserve days not numeric or lifetime

reserve days greater than 60

62 = Invalid number of covered days or covered

days < life time reserve days

65 = Operating cost-to-charge ratio not numeric

67 = Cost outlier with length of stay > covered days

68 = Provider specific state code invalid

72 = Invalid blend indicator (not 1 thru 5)

73 = Discharged before provider FY begin

date

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74 = Provider FY begin date not in

2002

A0 = Blend yr, site-neutral based on

cost, psych/rehab

A1 = Blend yr, site-neutral based on

cost, outlier, psych/rehab

A2 = Blend yr, site-neutral based on

cost, SSO, psych/rehab

A3 = Blend yr, site-neutral based on

cost, SSO, outlier, psych/rehab

A4 = Blend yr, site-neutral based on

IPPS, psych/rehab

A5 = Blend yr, site-neutral based on

IPPS, outlier, psych/rehab

A6 = Blend yr, site-neutral based on

IPPS, SSO, psych/rehab

A7 = Blend yr, site-neutral based on

IPPS, SSO, outlier, psych/rehab

AA = Site-neutral based on cost,

psych/rehab

AB = Site-neutral based on IPPS,

psych/rehab

AC = Site-neutral based on IPPS,

outlier, psych/rehab

B0 = Blend yr, site-neutral based on

cost, vent

B1 = Blend yr, site-neutral based on

cost, outlier, vent

B2 = Blend yr, site-neutral based

on cost, SSO, vent

B3 = Blend yr, site-neutral based

on cost, SSO, outlier, vent

B4 = Blend yr, site-neutral based on IPPS,

vent

B5 = Blend yr, site-neutral based on IPPS,

outlier, vent

B6 = Blend yr, site-neutral based on IPPS,

SSO, vent

B7 =Blend yr, site-neutral based on IPPS,

SSO, outlier, vent

BA = Site-neutral based on cost, vent

BB = Site-neutral based on IPPS, vent

BC = Site-neutral based on IPPS,

outlier, vent

BD = SSO standard payment, vent

BE = SSO standard payment, outlier,

vent

BF = Standard payment full DRG, vent

BG = Standard payment full DRG,

outlier, vent

C0 = Blend yr, site-neutral based on

cost, no vent

C1 = Blend yr, site-neutral based on

cost, outlier, no vent

C2 = Blend yr, site-neutral based on

cost, SSO, no vent

C3 = Blend yr, site-neutral based on

cost, SSO, outlier, no vent

C4 = Blend yr, site-neutral based on

IPPS, no vent

C5 = Blend yr, site-neutral based on

IPPS, outlier, no vent

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C6 = Blend yr, site-neutral based on

IPPS, SSO, no vent

C7 = Blend yr, site-neutral based on

IPPS, SSO, outlier, no vent

CA = Site-neutral based on cost, no

vent

CB = Site-neutral based on IPPS, no

vent

CC = Site-neutral based on

IPPS, outlier, no vent

CD = SSO standard payment, no vent

CE = SSO standard payment, outlier, no

vent

CF = Standard payment full DRG, no vent

CG = Standard payment full DRG, outlier,

no vent

*************SNF Pricer Return Codes*********

*******************TOB 21X*******************

SNF payment return codes:

00 = RUG III group rate returned

SNF Error return codes:

20 = Bad RUG code

30 = Bad MSA code

40 = Thru date < July 1, 1998 or

invalid

50 = Invalid federal blend for that

year

60 = Invalid federal blend

61 = Federal blend = 0 and SNF thru

date < January 1, 2000

*********Hospice Pricer Return Codes************

**************TOB 81X or 82X********************

Hospice payment return codes:

00 = Home rate returned

Hospice Error return codes:

10 = Bad units

20 = Bad units 2 < 8

30 = Bad MSA code

40 = Bad hospice wage index from MSA

file

50 = Bad bene wage index from MSA file

51 = Bad provider number

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*******Home Health Pricer Return Codes************

*****TOB 32X or 33X, DOS 10/1/2000 and after******

Home health payment return codes:

00 = Final payment where no outlier

applies

01 = Final payment where outlier

applies

03 = Initial percentage payment, 0%

04 = Initial percentage payment, 50%

05 = Initial percentage payment, 60%

06 = LUPA payment only

07 = Final payment, SCIC

08 = Final payment, SCIC with outlier

09 = Final payment, PEP

11 = Final payment, PEP with outlier

12 = Final payment, SCIC within PEP

13 = Final payment, SCIS within PEP with outlier

Home health error return codes:

10 = Invalid TOB

15 = Invalid PEP days

16 = Invalid HRG days, > 60

20 = PEP indicator invalid

25 = Med review indicator

invalid

30 = Invalid MSA code

35 = Invalid initial payment indicator

40 = Dates < October 1, 2000 or invalid

70 = Invalid HRG code

75 = No HRG present in 1st occurrence

80 = Invalid revenue code

85 = No revenue code present on HH final

claim/adjustment

************Outpatient PPS Pricer Return Codes******

Outpatient PPS payment return codes:

01 = Line processed to payment

20 = Line processed but payment = 0

bene deductible = > adjusted

payment

22 = For outpatient PPS, it means daily

coinsurance limitation

Outpatient PPS error return codes:

30 = Missing, deleted, or invalid APC

38 = Missing or invalid discount

factor

40 = Invalid service indicator passed

by the OCE

41 = Service indicator invalid for OPPS

PRICER

42 = APC = “00000” or (packaging flag = 1

or 2)

43 = Payment indicator not = to 1 or 5

thru 9

44 = Service indicator = “H” but payment

indicator not = to 6

45 = Packaging flag not = to 0

46 = Line-item denial/reject flag not = to 0 or

line-item denial/reject flag = to 1 and (APC

not = 0033 or 0034 or 0322 or 0323 or

0324 or 0325 or 0373 or 0374)) or line-

item action flag not = to 1

47 = Line-item action flag = 2 or 3

48 = Payment adjustment flag not valid

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49 = Site of service flag not = to 0 or

(APC 0033 is not on the claim and

service indicator = “P” or APC =

0322, 0325, 0373, 0374)

50 = Wage index not located

51 = Wage index equals zero

52 = Provider specific file wage index

reclassification code invalid or missing

53 = Service from date not numeric or <

20000801

54 = Service from date < provider effective

date or service from date > provider

termination date

***End-stage Renal Disease (ESRD) Pricer Return Codes***

ESRD payment return codes:

00 = ESRD PPS payment calculated 01 = ESRD facility rate > zero

ESRD error return codes:

22 = For ESRD Pricer, it means PPS

w/acute comorbid, training

26 = For ESRD Pricer, it means PPS

w/chronic comorbid, low

volume, training

31 = ESRD Pricer means PPS w/low

BMI

32 = ESRD Pricer means PPS w/low

volume, onset

33 = For ESRD Pricer, it means PPS

w/outlier, training

50 = ESRD facility rate not numeric

52 = Provider type not = “40” or

“41”

53 = Special payment indicator not = “1”

or blank

54 = Date of birth not numeric or = zero

55 = Patient weight not numeric or = zero

56 = Patient height not numeric or = zero

57 = Revenue center code not in range

58 = Condition code not = “73” or “74” or

blank

60 = MSA wage adjusted rate record not

found

98 = Claim through date before 4/1/2005

or not numeric

COMMENT: The payment return code identifies the type of payment calculated by the PRICER software.

^ Back to TOC ^

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CLM_PRCR_VRSN_CD

LABEL: Claim Pricer version Code

DESCRIPTION: This field indicates the prospective payment system (PPS) Pricer version used to process payment for

the claim.

SHORT NAME: CLM_PRCR_VRSN_CD

LONG NAME: CLM_PRCR_VRSN_CD

TYPE: CHAR

LENGTH: 10

SOURCE: NCH

VALUES: These are examples of observed values; this is not a comprehensive list.

2022.1

C2022.1

SNFPR22.1

COMMENT: This field is not populated prior to 2021.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

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CLM_RLT_COND_CD

LABEL: Claim Related Condition Code

DESCRIPTION: The code that indicates a condition relating to an institutional claim that may affect payer processing.

SHORT NAME: RLT_COND

LONG NAME: CLM_RLT_COND_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES:

01 THRU 16 = Insurance related

17 THRU 30 = Special condition

31 THRU 35 = Student status codes

which are required

when a patient is a

dependent child over 18

years old

36 THRU 45 = Accommodation

46 THRU 54 = CHAMPUS information

55 THRU 59 = Skilled nursing facility

60 THRU 70 = Prospective payment

71 THRU 99 = Renal dialysis setting

A0 THRU B9 = Special program codes

C0 THRU C9 = QIO approval services

D0 THRU W0 = Change conditions

===========================================

01 = Military service related — medical

condition incurred during military

service

02 = Employment related — patient

alleged that the medical condition

causing this episode of care was

due to environment/events

resulting from employment

03 = Patient covered by insurance not

reflected here — indicates that

patient or patient representative

has stated that coverage may

exist beyond that reflected on this

bill

04 = Health Maintenance

Organization (HMO) enrollee —

Medicare beneficiary is enrolled

in an HMO. Hospital must also

expect to receive payment from

HMO

05 = Lien has been filed — provider has filed

legal claim for recovery of funds

potentially due a patient as a result of

legal action initiated by or on behalf of

the patient

06 = ESRD patient in the first 30 months of

entitlement covered by employer group

health insurance

07 = Treatment of nonterminal condition for

hospice patient — the patient is a hospice

enrollee, but the provider is not treating a

terminal condition and is requesting

Medicare reimbursement

08 = Beneficiary would not provide

information concerning other insurance

coverage

09 = Neither patient nor spouse is employed

— code indicates that in response to

development questions, the patient and

spouse have denied employment

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10 = Patient and/or spouse is

employed but no EGHP coverage

exists or other employer

sponsored/provided health

insurance covering patient

11 = The disabled beneficiary and/or

family member has no group

coverage from a LGHP or other

employer sponsored/provided

health insurance covering patient

12 = Payer code — reserved for

internal use only by third party

payers. CMS will assign as needed.

Providers will not report them

13 = Payer code — reserved for

internal use only by third party

payers. CMS will assign as needed.

Providers will not report them

14 = Payer code — reserved for

internal use only by third party

payers. CMS will assign as needed.

Providers will not report them

15 = Payer code — Clean claim.

Delayed in CMS's processing

system

16 = Payer code — SNF transition

exemption — an exemption

from the post-hospital

requirement applies for this SNF

stay or the qualifying stay dates

are more than 30 days before

the admission date

17 = Patient is homeless

18 = Maiden name retained — a

dependent spouse entitled to

benefits who does not use her

husband's last name

19 = Child retains mother's name — a

patient who is a dependent child

entitled to CHAMPVA benefits that

does not have father's last name

20 = Beneficiary requested billing —

provider realizes the services on

this bill are at a non-covered level

of care or otherwise excluded from

coverage, but the bene has

requested formal determination

21 = Billing for denial notice — the SNF

or HHA realizes services are at a

non-covered level of care or

excluded but requests a Medicare

denial in order to bill Medicaid or

other insurer

22 = Patient on multiple drug regimen

— a patient who is receiving

multiple intravenous drugs while

on home IV therapy

23 = Home caregiver available — the

patient has a caregiver available to

assist him or her during self-

administration of an intravenous

drug

24 = Home IV patient also receiving

HHA services — the patient is

under care of HHA while receiving

home IV drug therapy services

25 = Reserved for national assignment

26 = VA eligible patient chooses to receive

services in Medicare certified facility

rather than a VA facility

27 = Patient referred to a sole community

hospital for a diagnostic laboratory

test — (sole community hospital

only)

28 = Patient and/or spouse's EGHP is

secondary to Medicare — Qualifying

EGHP for employers who have fewer

than 20 employees

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29 = Disabled beneficiary and/or

family member's LGHP is

secondary to Medicare —

qualifying LGHP for employer

having fewer than 100 full and

part-time employee

30 = Qualifying clinical trials — non-

research services provided to all

patients, including managed care

enrollees, enrolled in a qualified

clinical trial

31 = Patient is student (full time —

day) — patient declares that he or

she is enrolled as a full-time day

student

32 = Patient is student

(cooperative/work study

program)

33 = Patient is student (full time-night)

— patient declares that he or she

is enrolled as a full-time night

student

34 = Patient is student (part time) —

patient declares that he or she is

enrolled as a part-time student

35 = PACE eligible patient disenrolls

during an inpatient admission

(eff. 1/2024)

36 = General care patient in a special

unit — patient is temporarily

placed in special care unit bed

because no general care beds

were available

37 = Ward accommodation at

patient's request — patient is

assigned to ward

accommodations at patient's

request

38 = Semi-private room not available —

indicates that either private or ward

accommodations were assigned because

semi-private accommodations were not

available

39 = Private room medically necessary —

patient needed a private room for

medical reasons

40 = Same day transfer — patient transferred

to another facility before midnight of the

day of admission

41 = Partial hospitalization services. For OP

services, this includes a variety of

psychiatric programs

42 = Continuing care not related to inpatient

admission — continuing care not related

to the condition or diagnosis for which

the beneficiary received inpatient

hospital services. (eff. 10/2001)

43 = Continuing care not provided within

prescribed post-discharge window —

continuing care was related to the

inpatient admission, but the prescribed

care was not provided within the post-

discharge window. (eff. 10/2001)

44 = Inpatient admission changed to

outpatient — for use on outpatient

claims only, when the physician ordered

inpatient services, but upon internal

review performed before the claim was

initially submitted, the hospital

determined the services did not meet its

inpatient criteria. (eff. 4/2004)

45 = Gender incongruence (eff. 7/2023)

46 = Non-availability statement on file for

TRICARE claim for nonemergency IP

care for TRICARE bene residing within

the catchment area (usually a 40-mile

radius) of a uniform services hospital

47 = Reserved for TRICARE

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48 = Psychiatric residential treatment

centers for children and

adolescents (RTCs). Claims

submitted by TRICARE

49 = Product replacement within

product lifecycle — replacement

of a product earlier than the

anticipated lifecycle due to an

indication that the product is not

functioning properly (eff. 4/2006)

50 = Product replacement for known

recall of a product — manufacturer

or FDA has identified the product

for recall and therefore

replacement (eff. 4/2006)

51 = Attestation of unrelated

outpatient nondiagnostic services

(eff. 4/2011)

52 = Reserved for national assignment

53 = Initial placement of a medical

device provided as part of a

clinical trial or a free sample (eff.

7/2015)

54 = No skilled HH visits in billing

period (eff. 7/2016)

55 = SNF bed not available — the

patient's SNF admission was

delayed more than 30 days after

hospital discharge because a SNF

bed was not available

56 = Medical appropriateness —

patient's SNF admission was

delayed more than 30 days after

hospital discharge because

physical condition made it

inappropriate to begin active

care within that period

57 = SNF readmission — patient previously

received Medicare covered SNF care

within 30 days of the current SNF

admission

58 = Terminated managed care

organization enrollee — patient is a

terminated enrollee in a Managed

Care plan whose three-day

inpatient hospital stay was waived

59 = Non-primary ESRD facility — ESRD

beneficiary received non-scheduled

or emergency dialysis services at a

facility other than his/her primary

ESRD dialysis facility (eff. 10/2004)

60 = Operating cost day outlier —

PRICER indicates this bill is length of

stay outlier (PPS)

61 = Operating cost outlier — PRICER

indicates this bill is a cost outlier

(PPS)

62 = Payer code — PIP bill — this bill is a

periodic interim payment bill

63 = Payer code — reserved for internal

payer use only. CMS assigns as

needed. Providers do not report

this code. Indicates services

rendered to a prisoner or patient in

state or local custody meeting

requirements of 42 CFR 411.4(b)

64 = Payer code — other than clean

claim — the claim is not a “clean

claim”

65 = Payer code — non-PPS bill — the

bill is not a prospective payment

system bill

66 = Hospital does not wish cost outlier

payment — bill may meet the

criteria for cost outlier, but the

hospital did not claim the cost

outlier (PPS)

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67 = Beneficiary elects not to use

lifetime reserve (LTR) days

68 = Beneficiary elects to use LTR days

69 = IME/DGME/NandA payment only

— providers request for request

for a supplemental payment for

IME/DGME/NandAH (Indirect

Medical Education/Graduate

Medical Education/Nursing and

Allied Health)

70 = Self-administered Epoetin (EPO)

— billing is for a home dialysis

patient who self-administers EPO

71 = Full care in unit — billing is for a

patient who received staff

assisted dialysis services in a

hospital or renal dialysis facility

72 = Self-care in unit — billing is for a

patient who managed his own

dialysis services without staff

assistance in a hospital or renal

dialysis facility

73 = Self-care training — billing is for

special dialysis services where the

patient and helper (if necessary)

were learning to perform dialysis

74 = Home — billing is for a patient

who received dialysis services at

home

75 = Home dialysis patient using a

dialysis machine that was

purchased under the 100%

program

76 = Back-up in facility dialysis —

billing is for a patient who

received dialysis services in a

back-up facility

77 = Provider accepts or is obligated/

required due to contractual

agreement or law to accept payment

by the primary payer as payment in

full — no Medicare payment is due

78 = New coverage not implemented by

HMO, indicates newly covered

service under Medicare for which

HMO does not pay

79 = CORF services provided off site —

code indicates that physical therapy,

occupational therapy, or speech

pathology services were provided off

site

80 = Home dialysis — nursing facility —

home dialysis furnished in a SNF or

nursing facility (eff. 4/2005).

Reported with condition code 74

81 = C-sections/inductions < 39 weeks —

medical necessity (eff. 10/1/13)

82 = C-sections/inductions < 39 weeks —

elective (eff. 10/2013)

83 = C-sections/inductions 39 weeks or

greater (eff. 10/2013)

84 = Dialysis for acute kidney injury (AKI)

(eff. 1/2017)

85 = Delayed recertification of hospice

terminal Illness (eff. 1/2017)

86 = Additional hemodialysis treatments

with medical justification (eff. date

TBD)

87 = ESRD self-care retraining (eff.

7/2017)

88 = Allogeneic stem cell transplant

related donor charges (eff. 7/2020)

89 = Opioid treatment program (OTP) —

indicates claim is for opioid

treatment services (eff. 1/2021)

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90 = Service provided as part of an

expanded access approval (EA)

to the IPPS price. Code is for

inpatient and outpatient claims

that have re-ported EA) services

(eff. 7/2021)

91 = Service provided as part of an

emergency use authorization

(EUA) to the IPPS pricer. Code is

for inpatient and outpatient

claims that have reported

emergency EUA services (eff.

7/2021)

92 = Intensive outpatient program

(IOP) (eff. 1/2024)

93–97 = Reserved for state

assignment

98 = Payer code — data associated

with DRG 468 has been validated

(eff. 7/2023)

A0 = TRICARE External Partnership

Program — this code identifies

TRICARE claims submitted under

the external partnership program.

(previously this was a special zip

code reporting — five-digit zip

code of the location from which

the beneficiary is initially placed

on board the ambulance; (eff.

9/2001); obsolete

A1 = EPSDT/CHAP — early and

periodic screening diagnosis and

treatment special program

indicator code

A2 = Physically handicapped children's

program — services provided

receive special funding through

Title 8 of the Social Security Act or

the CHAMPUS program for the

handicapped

A3 = Special federal funding — designed

for uniform use by state uniform

billing committees. Special program

indicator code

A4 = Family planning — designed for

uniform use by state uniform billing

committees. Special program

indicator code

A5 = Disability — designed for uniform use

by state uniform billing committees

A6 = PPV/Medicare — identifies that

pneumococcal pneumonia 100%

payment vaccine (PPV) services

should be reimbursed under a special

Medicare program provision

A7 = Induced abortion to avoid danger to

woman's life

A8 = Induced abortion — victim of

rape/incest. Special program indicator

code

A9 = Second opinion surgery — services

requested to support second opinion

on surgery. Part B deductible and

coinsurance do not apply

AA = Abortion performed due to rape (eff.

10/2002)

AB = Abortion performed due to incest

(eff. 10/2002)

AC = Abortion performed due to serious

fetal genetic defect, deformity, or

abnormality (eff. 10/2002)

AD = Abortion performed due to a life

endangering physical condition

caused by, arising from, or

exacerbated by the pregnancy itself

(eff. 10/2002)

AE = Abortion performed due to physical

health of mother that is not life

endangering (eff. 10/2002)

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AF = Abortion performed due to

emotional/psychological health

of mother (eff. 10/2002)

AG = Abortion performed due to

social economic reasons (eff.

10/2002)

AH = Elective abortion (eff. 10/2002)

AI = Sterilization (eff. 10/2002)

AJ = Payer responsible for copayment

(eff. 4/2003)

AK = Air ambulance required — for

ambulance claims. Time needed

to transport poses a threat. (eff.

10/2003)

AL = Specialized treatment/bed

unavailable — for ambulance

claims. Specialized treatment

bed unavailable. Transported to

alternate facility. (eff. 10/2003)

AM = Non-emergency medically

necessary stretcher transport

required — for ambulance claims.

Non-emergency medically

necessary stretcher transport

required. (eff. 10/2003)

AN = Preadmission screening not

required — person meets the

criteria for an exemption from

preadmission screening. (eff.

1/2004)

B0 = Medicare Coordinated Care

Demonstration Program —

patient is a participant in a

Medicare Coordinated Care

Demonstration (eff. 10/2001)

B1 = Beneficiary ineligible for

demonstration program (eff.

1/2002)

B2 = Critical access hospital ambulance

attestation — attestation by CAH

that it meets the criteria for

exemption from the ambulance fee

schedule

B3 = Pregnancy indicator — indicates the

patient is pregnant. Required when

mandated by law (eff. 10/2003)

B4 = Admission unrelated to discharge —

admission unrelated to discharge on

same day. This code is for discharges

starting on January 1, 2004

B5 = Special program indicator reserved

for national assignment

B6 = Special program indicator reserved

for national assignment

B7 = Special program indicator reserved

for national assignment

B8 = Special program indicator reserved

for national assignment

B9 = Special program indicator reserved

for national assignment

C0 = Reserved for national assignment

C1 = Approved as billed — claim has been

reviewed by the QIO and has been

fully approved including any outlier

C2 = QIO approval indicator services.

NOTE: Beginning July 2005, this code

is relevant to type of bills other than

inpatient (18X, 21X, 22X, 32X, 33X,

34X, 75X, 81X, 82X)

C3 = Partial approval — some portion

(days or services). From/Through

dates of the approved portion of the

stay are shown as code “M0” in FL

36. The hospital excludes grace days

and any period at a non-covered

level of care (code “77” in FL 36 or

code “46” in FL 39–41)

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C4 = Admission denied — the

patient’s need for inpatient

services was reviewed and the

QIO found that none of the stay

was medically necessary

C5 = Post-payment review applicable

— any medical review will be

completed after the claim is

paid. This bill may be a day

outlier, cost outlier, part of the

sample review, reviewed for

other reasons, or may not be

reviewed

C6 = Preadmission/Pre-procedure

authorization — the QIO

authorized this

admission/procedure but has

not reviewed the services

provided

C7 = Extended authorization — the

QIO has authorized these

services for an extended length

of time but has not reviewed the

services provided

C8 = Reserved for national assignment.

QIO approval indicator services

C9 = Reserved for national assignment.

QIO approval indicator services

D0 = Changes to service dates

D1 = Changes in charges

D2 = Changes in revenue

codes/HCPCS/HIPPS rate code —

report this claim change reason

code on a replacement claim (bill

type frequency code 7) to reflect

a change in revenue codes

(FL42)/HCPCS/HIPPS rate codes

(FL44)

D3 = Second or subsequent interim

PPS bill

D4 = Change in ICD-9-CM diagnosis and/or

procedure code

D5 = Cancel only to correct a beneficiary

claim account number (HICN) or

provider identification number

D6 = Cancel only to repay a duplicate

payment or OIG overpayment

(includes cancellation of an outpatient

bill containing services required to be

included on the inpatient bill)

D7 = Change to make Medicare the

secondary payer

D8 = Change to make Medicare the primary

payer

D9 = Any other change

DR = Disaster relief (eff. 10/2005) — code

used to facilitate claims processing and

track services/items provided to

victims of disasters

E0 = Change in patient status

EY = Payer code — National Emphysema

Treatment Trial (NETT) or Lung Volume

Reduction Surgery (LVRS) clinical study

G0 = Distinct medical visit — report this code

when multiple medical visits occurred

on the same day in the same revenue

center. The visits were distinct and

constituted independent visits

H0 = Delayed filing, statement of intent

submitted — statement of intent was

submitted within the qualifying period

to specifically identify the existence of

another third-party liability situation

H3 = Reoccurrence of GI bleed comorbid

category (eff. 1/2011)

H4 = Reoccurrence of pneumonia category

(eff. 1/2011)

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H5 = Reoccurrence of pericarditis

comorbid category (eff. 1/2011)

M0 = Payer only — all-inclusive rate

for outpatient services. Used by

a critical access hospital

electing to be paid an all-

inclusive rate for outpatient

services. Obsolete

M1 = Payer code — roster billed

influenza virus vaccine or

pneumococcal pneumonia

vaccine (PPV). Obsolete

M2 = Payer code — HHA payment

significantly exceeds total

charges — used when payment

to an HHA is significantly more

than covered billed charges.

Obsolete

M3 = Payer code — SNF three-day

stay bypass for NG/Pioneer ACO

waiver (eff. 7/2023)

M4 = Payer code — presence of

infected wound or wound with

morbid obesity (eff. 7/2023)

M5 = Payer code — not currently

used by Medicare (eff. 7/2023)

M6 = Payer code — Pennsylvania

(PA) Rural Health Model

(PARHM)

M7 = Payer only — shared system

Medicare deductible bypass

(eff. 7/2023)

M8 = Payer only — shared system

Medicare coinsurance bypass

(eff. 7/2023)

M9 = Payer only — shared system

Medicare deductible/coinsurance

bypass (eff. 7/2023)

MA = Payer code — GI bleed. (bill type

072x), Managed Care enrollee (bill

type 012x, 013x, and 076x)

MB = Payer code — pneumonia. (bill type

072x)

MC = Payer code — pericarditis. (bill type

072x)

MD = Payer code — myelodysplastic

Syndrome (bill type 072x)

ME = Payer code — hereditary hemolytic

and sickle cell anemia (bill type 072x)

MF = Payer code — monoclonal

gammopathy (bill type 072x)

MG = Payer code — Grandfathered Tribal

Federally Qualified Health Centers

MH = Payer only — MAC Medicare

deductible bypass (eff. 7/2023); Acute

hospital care at home (payer only

code) (eff. 7/2021)

MI = Payer only — MAC Medicare

coinsurance bypass (eff. 7/2023)

MJ = Payer only — MAC Medicare

deductible/coinsurance bypass (eff.

7/2023)

MO = Payer code — MAC override appeal

timeliness

MP = Payer code — PHP claim contains

initial admit week

MQ = Payer code — PHP claim contains

final discharge week

MS = Payer only — Medicare SNF three-day

edit bypass (eff. 7/2023)

MV = Payer code — 20 hours for partial PHP

subsequent week not met

MW = Payer code — 20 hours for partial

PHP initial week net met

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MX = Payer code — wrong surgery on

patient (inpatient)

MY = Payer code — surgery wrong

body part (inpatient), outlier cap

bypass (CMHC)

MZ = Payer code — surgery wrong

patient (inpatient), IOCE error

code bypass (outpatient)

R1 = Request for reopening reason

code — mathematical or

computational mistakes (eff.

1/2016)

R2 = Request for reopening reason

code — inaccurate data entry (eff.

1/2016)

R3 = Request for reopening reason

code — misapplication of a fee

schedule (eff. 1/2016)

R4 = Request for reopening reason

code — computer errors (eff.

1/2016)

R5 = Request for reopening reason

code — incorrectly identified

duplicate claim (eff. 1/2016)

R6 = Request for reopening reason

code — other clerical errors or

minor errors and omissions not

specified in R1–R5 above (eff.

1/2016)

R7 = Request for reopening reason code

— corrections other than clerical

errors (eff. 1/2016)

R8 = Request for reopening reason code

— new and material evidence (eff.

1/2016)

R9 = Request for reopening reason code

— faulty evidence (eff. 1/2016)

UU = Payer code — not currently used

by Medicare

W0 = United Mine Workers of America

(UMWA) SNF demonstration

indicator

XX = Transgender/Hermaphrodite

beneficiaries (eff. 1/2007)

ZA = Payer code — inpatient. Positive

test result is not included in the

patient's medical record. (eff.

7/2021)

ZB = Payer code — inpatient. Service

provided as part of an expanded

access approval. (eff. 7/2021)

ZC = Payer code — inpatient. Clinical

trial of a different product

ZD–ZZ = Reserved. Payer code — not

currently in use by Medicare

Z0 = PACE straddle claim

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 130

CLM_RLT_OCRNC_CD

LABEL: Claim Related Occurrence Code

DESCRIPTION: The code that identifies a significant event relating to an institutional claim that may affect payer

processing.

These codes are associated with a specific date (the claim related occurrence date).

SHORT NAME: OCRNC_CD

LONG NAME: CLM_RLT_OCRNC_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES:

01 THRU 09 = Accident

10 THRU 19 = Medical condition

20 THRU 39 = Insurance related

40 THRU 69 = Service related

A1–A3= Miscellaneous

===========================================

01 = Auto accident — the date of an

auto accident

02 = No-fault insurance involved,

including auto accident/other —

the date of an accident where the

state has applicable no-fault

liability laws, (i.e., legal basis for

settlement without admission or

proof of guilt)

03 = Accident/tort liability — the date

of an accident resulting from a

third party's action that may

involve a civil court process in an

attempt to require payment by

the third party, other than no-

fault liability

04 = Accident/employment related —

the date of an accident relating to

the patient's employment

05 = Other accident — the date of an

accident not described by the

codes 01 thru 04

06 = Crime victim — code indicating the

date on which a medical condition

resulted from alleged criminal action

committed by one or more parties

07 = Reserved for national assignment

08 = Reserved for national assignment

11 = Onset of symptoms/illness — the

date the patient first became aware

of symptoms/illness

12 = Date of onset for a chronically

dependent individual — code

indicates the date the patient/bene

became a chronically dependent

individual

13 = Reserved for national assignment

14 = Reserved for national assignment

15 = Reserved for national assignment

16 = Reserved for national assignment

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17 = Date outpatient occupational

therapy plan established or last

reviewed — code indicating the

date an occupational therapy plan

was established or last reviewed

18 = Date of retirement (patient/bene)

— code indicates the date of

retirement for the patient/bene

19 = Date of retirement spouse —

code indicates the date of

retirement for the patient's

spouse

20 = Guarantee of payment began —

the date on which the provider

began claiming Medicare

payment under the guarantee of

payment provision

21 = UR notice received — code

indicating the date of receipt by

the hospital and SNF of the UR

committee's finding that the

admission or future stay was not

medically necessary

22 = Active care ended — the date on

which a covered level of care

ended in a SNF or general

hospital, or date active care

ended in a psychiatric or

tuberculosis hospital or date on

which patient was released on a

trial basis from a residential

facility. Code is not required if

code "21" is used

23 = Payer only — date of

cancellation of hospice benefits

— the date the RHHI cancelled

the hospice benefit. (eff.

10/2000). NOTE: This will be

different than the revocation of

the hospice benefit by

beneficiaries

24 = Date insurance denied — the date

the insurer's denial of coverage was

received by a higher priority payer

25 = Date benefits terminated by primary

payer — the date on which coverage

(including worker's compensation

benefits or no-fault coverage) is no

longer available to the patient

26 = Date skilled nursing facility (SNF) bed

available — the date on which a SNF

bed became available to a hospital

inpatient who required only SNF

level of care

27 = Date of hospice certification or re-

certification — code indicates the

date of certification or recertification

of the hospice benefit period,

beginning with the first two initial

benefit periods of 90 days each and

the subsequent 60-day benefit

periods. (eff. 9/2001)

27 = Date home health plan established

or last reviewed — code indicating

the date a home health plan of

treatment was established or last

reviewed. (Obsolete) not used by

hospital unless owner of facility

28 = Date comprehensive outpatient

rehabilitation plan established or last

reviewed — code indicating the date

a comprehensive outpatient

rehabilitation plan was established

or last reviewed. Not used by

hospital unless owner of facility

29 = Date OPT plan established or last

reviewed — the date a plan of

treatment was established for

outpatient physical therapy. Not

used by hospital unless owner of

facility

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30 = Date speech pathology plan

treatment established or last

reviewed — the date a speech

pathology plan of treatment was

established or last reviewed. Not

used by hospital unless owner of

facility

31 = Date bene notified of intent to bill

(accommodations) — the date of

the notice provided to the patient

by the hospital stating that he no

longer required a covered level of

IP care

32 = Date bene notified of intent to bill

(procedures or treatment) — the

date of the notice provided to the

patient by the hospital stating

requested care (diagnostic

procedures or treatments) is not

considered reasonable or

necessary

33 = First day of the Medicare

coordination period for ESRD

bene — during which Medicare

benefits are secondary to benefits

payable under an EGHP. Required

only for ESRD beneficiaries

34 = Date of election of extended care

facilities — the date the guest

elected to receive extended care

services (used by Religious

Nonmedical Health Care

Institutions only)

35 = Date treatment started for

physical therapy — code

indicates the date services were

initiated by the billing provider

for physical therapy

36 = Date of discharge for the IP

hospital stay when patient

received a transplant procedure

— hospital is billing for

immunosuppressive drugs

37 = The date of discharge for the IP

hospital stay when patient received a

non-covered transplant procedure —

hospital is billing for

immunosuppressive drugs

38 = Date treatment started for home IV

therapy — date the patient was first

treated in his home for IV therapy

39 = Date discharged on a continuous course

of IV therapy — date the patient was

discharged from the hospital on a

continuous course of IV therapy

40 = Scheduled date of admission — the date

on which a patient will be admitted as an

inpatient to the hospital. (This code may

only be used on an outpatient claim.)

41 = Date of first test for pre-admission

testing — the date on which the first

outpatient diagnostic test was

performed as part of a pre-admission

testing (PAT) program. This code may

only be used if a date of admission was

scheduled prior to the administration

of the test(s). (eff. 10/2001)

42 = Date of discharge/termination of hospice

care — for the final bill for hospice care.

Date patient revoked hospice election

43 = Scheduled date of canceled surgery —

date which ambulatory surgery was

scheduled. (eff. 9/2001)

44 = Date treatment started for

occupational therapy — code

indicates the date services were

initiated by the billing provider for

occupational therapy

45 = Date treatment started for speech

therapy — code indicates the date

services were initiated by the billing

provider for speech therapy

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46 = Date treatment started for

cardiac rehabilitation — code

indicates the date services were

initiated by the billing provider

for cardiac rehabilitation

47 = Date cost outlier status begins —

code indicates that this is the first

day the cost outlier threshold is

reached. For Medicare purposes,

a bene must have regular

coinsurance and/or lifetime

reserve days available beginning

on this date to allow coverage of

additional daily charges for the

purpose of making cost outlier

payments. (eff. 9/2001)

48 = Payer only — not currently used

by Medicare

49 = Payer only — original Notice of

Election (NOE) receipt date

50–55 = Reserved for state assignment

56 = Hospice — incorrect date of

hospice notification of election

(NOE). This code indicates the

date of certification or

recertification of the hospice

benefit period, which has been

corrected (the corrected date

appears in the record for

occurrence code = 26). (eff.

1/2018)

57–60 = Reserved for state assignment

61 = Hospital discharge date (HHA

only) (eff. 1/2020)

62 = Other institutional discharge date

(HHA only) (eff. 1/2020)

A1 = Birthdate, insured A — the

birthdate of the individual in

whose name the insurance is

carried

A2 = Effective date, insured A policy —

code indicating the first date

insurance is in force

A3 = Benefits exhausted — code

indicating the last date for which

benefits are available and after

which no payment can be made to

payer A

A4 = Split bill date — date patient became

eligible due to medically needy

spend down (sometimes referred to

as "split bill date")

B1 = Birthdate, insured B — the birthdate

of the individual in whose name the

insurance is carried

B2 = Effective date, insured B policy —

code indicating the first date

insurance is in force

B3 = Benefits exhausted — code

indicating the last date for which

benefits are available and after

which no payment can be made to

payer B

C1 = Birthdate, insured C — the birthdate

of the individual in whose name the

insurance is carried

C2 = Effective date, insured C policy — a

code indicating the first date

insurance is in force

C3 = Benefits exhausted — code indicating

the last date for which benefits are

available and after which no payment

can be made to payer C

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 134

CLM_RLT_OCRNC_DT

LABEL: Claim Related Occurrence Date

DESCRIPTION: The date associated with a significant event related to an institutional claim that may affect payer

processing.

The date for the event that appears in the claim related occurrence code field.

SHORT NAME: OCRNCDT

LONG NAME: CLM_RLT_OCRNC_DT

TYPE: DATE

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 135

CLM_RP_IND_CD

LABEL: Claim Representative Payee (RP) Indicator Code

DESCRIPTION: Claim representative payee (RP) indicator code.

SHORT NAME: CLM_RP_IND_CD

LONG NAME: CLM_RP_IND_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: R = bypass representative payee

Null/missing = not applicable

COMMENT: This field is used to designate by-passing of the prior authorization processing for claims with a

representative payee when an “R” is present in the field.

This field was added in April 2018.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 136

CLM_RSDL_PYMT_IND_CD

LABEL: Claim Residual Payment Indicator Code

DESCRIPTION: Claim residual payment indicator code.

SHORT NAME: CLM_RSDL_PYMT_IND_CD

LONG NAME: CLM_RSDL_PYMT_IND_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: X = Residual payment

Null/missing = not applicable

COMMENT: This field is used by CWF claims processing for the purpose of bypassing its normal MSP editing that

would otherwise apply for ongoing responsibility for medicals (ORM) or worker's compensation

Medicare Set-Aside Arrangements (WCMSA). Normally, CWF does not allow a secondary payment on

MSP involving ORM or WCMSA, so the residual payment indicator will be used to allow CWF to make

an exception to its normal routine.

This field appears in the data starting April 2008.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 137

CLM_SITE_NTRL_PYMT_CST_AMT

LABEL: Claim Site Neutral Payment Based on Cost Amount

DESCRIPTION: Under the long-term care hospital (LTCH) prospective payment system (PPS), the payment amount

based on estimated cost of the case.

SHORT NAME: CLM_SITE_NTRL_PYMT_CST_AMT

LONG NAME: CLM_SITE_NTRL_PYMT_CST_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: Applies only to inpatient (LTCH) claims. This field is new in October 2015.

For a LTCH PPS claim, only one of four fields will be populated (CLM_SITE_NTRL_PYMT_CST_AMT,

CLM_SITE_NTRL_PYMT_IPPS_AMT, CLM_FULL_STD_PYMT_AMT, or

CLM_SS_OUTLIER_STD_PYMT_AMT) as they are mutually exclusive (i.e., only one of the four fields will

have a non-zero value). The field with the non-zero value is included in the Claim Payment Amount

field.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 138

CLM_SITE_NTRL_PYMT_IPPS_AMT

LABEL: Claim Site Neutral Payment Based on Inpatient Prospective Payment System (IPPS) Amounts

DESCRIPTION: Under the long-term care hospital (LTCH) prospective payment system (PPS), the payment amount

based on the inpatient prospective payment system (IPPS) comparable amount. This amount does not

include any applicable outlier payment amount.

SHORT NAME: CLM_SITE_NTRL_PYMT_IPPS_AMT

LONG NAME: CLM_SITE_NTRL_PYMT_IPPS_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: Applies only to inpatient (LTCH) claims. This field is new in October 2015.

For a LTCH PPS claim, only one of four fields will be populated (CLM_SITE_NTRL_PYMT_CST_AMT,

CLM_SITE_NTRL_PYMT_IPPS_AMT, CLM_FULL_STD_PYMT_AMT, or

CLM_SS_OUTLIER_STD_PYMT_AMT) as they are mutually exclusive (i.e., only one of the 4 fields will

have a non-zero value). The field with the non-zero value is included in the Claim Payment Amount

field.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 139

CLM_SPAN_CD

LABEL: Claim Occurrence Span Code

DESCRIPTION: The code that identifies a significant event relating to an institutional claim that may affect payer

processing.

These codes are claim-related occurrences that are related to a time period span of dates (variables

called the CLM_SPAN_FROM_DT and CLM_SPAN_THRU_DT).

SHORT NAME: SPAN_CD

LONG NAME: CLM_SPAN_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES:

70 = Payer use only, the non-utilization

from/thru dates for PPS-inlier stay

where bene had exhausted all

full/coinsurance days but covered on

cost report. SNF qualifying hospital

stay from/thru dates

71 = Hospital prior stay dates — the

from/thru dates of any hospital stay

that ended within 60 days of this

hospital or SNF admission

72 = First/Last visit — the dates of the

first and last visits occurring in this

billing period if the dates are

different from those in the

statement covers period

73 = Benefit eligibility period — the

inclusive dates during which

CHAMPUS medical benefits are

available to a sponsor's bene as

shown on the bene's ID card

74 = Non-covered level of care — the

from/thru dates of a period at a non-

covered level of care in an otherwise

covered stay, excluding any period

reported with occurrence span code

76, 77, or 79

75 = The from/thru dates of SNF level of care

during IP hospital stay. Shows PRO

approval of patient remaining in hospital

because SNF bed not available. Not

applicable to swing bed cases. PPS

hospitals use in day outlier cases only

76 = Patient liability — from/thru dates of

period of non-covered care for which

hospital may charge bene. The FI or PRO

must have approved such charges in

advance. Patient must be notified in

writing three days prior to non-covered

period

77 = Provider liability (utilization charged) —

the from/thru dates of period of non-

covered care for which the provider is

liable. Applies to provider liability where

bene is charged with utilization and is

liable for deductible/coinsurance

78 = SNF prior stay dates — the from/thru

dates of any SNF stay that ended within

60 days of this hospital or SNF admission

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79 = Payer code — verified non-

covered stay dates for which the

provider is liable

80 = Prior Same-SNF Stay Dates for

Payment Ban Purposes — the

from/thru dates of a prior same-

SNF stay indicating a patient

resided in the SNF prior to, and if

applicable, during a payment

ban period up until their

discharge to a hospital

81 = Antepartum Days (eff. 7/2/12)

82 = Hospital at Home Care Dates —

the from/through dates of a

period of hospital at home care

provided during an inpatient

hospital stay. (eff. 7/2022)

83–99 = Reserved for national

assignment

M0 = PRO/UR approved stay dates —

the first and last days that were

approved where not all of the

stay was approved

M1 = Provider liability no utilization —

from/thru dates of a period of non-

covered care that is denied due to

lack of medical necessity or

custodial care for which the

provider is liable. (eff. 10/2001)

M2 = Dates of inpatient respite care —

from/thru dates of a period of

inpatient respite care for hospice

patients. (eff. 10/2000)

M3 = ICF Level of Care — the

from/through dates of a period of

intermediate level of care during an

inpatient hospital stay

M4 = Residential Level of Care — the

from/through dates of a period of

residential level of care during an

inpatient hospital stay

MR = Reserved for disaster related

occurrence span code

Z0-Z9 = Payer code — not currently used

by Medicare

ZA-ZZ – Payer code — not currently used

by Medicare

COMMENT: —

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CLM_SPAN_FROM_DT

LABEL: Claim Occurrence Span From Date

DESCRIPTION: The from date of a period associated with an occurrence of a specific event relating to an institutional

claim that may affect payer processing.

The first date associated with the claim occurrence span code (variable called the CLM_SPAN_CD).

SHORT NAME: SPANFROM

LONG NAME: CLM_SPAN_FROM_DT

TYPE: DATE

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 142

CLM_SPAN_THRU_DT

LABEL: Claim Occurrence Span Through Date

DESCRIPTION: The thru date of a period associated with an occurrence of a specific event relating to an institutional

claim that may affect payer processing.

The last date associated with the claim occurrence span code (variable called the CLM_SPAN_CD).

SHORT NAME: SPANTHRU

LONG NAME: CLM_SPAN_THRU_DT

TYPE: DATE

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 143

CLM_SRC_IP_ADMSN_CD

LABEL: Claim Source Inpatient Admission Code

DESCRIPTION: The code indicating the source of the referral for the admission or visit.

SHORT NAME: SRC_ADMS

LONG NAME: CLM_SRC_IP_ADMSN_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: For inpatient/SNF claims:

0 = ANOMALY: invalid value, if present,

translate to “9”

1 = Non-Health Care Facility Point of

Origin (Physician Referral) — the

patient was admitted to this facility

upon an order of a physician

2 = Clinic referral — the patient was

admitted upon the

recommendation of this facility's

clinic physician

3 = HMO referral — reserved for

national Prior to 3/08, HMO referral

— the patient was admitted upon

the recommendation of a health

maintenance organization (HMO)

physician

4 = Transfer from hospital (Different

Facility) — the patient was

admitted to this facility as a

hospital transfer from an acute care

facility where he or she was an

inpatient

5 = Transfer from a skilled nursing

facility (SNF) or Intermediate Care

Facility (ICF) — the patient was

admitted to this facility as a

transfer from a SNF or ICF where he

or she was a resident

6 = Transfer from another health care

facility — the patient was admitted to

this facility as a transfer from another

type of health care facility not defined

elsewhere in this code list where he or

she was an inpatient

7 = Emergency room — the patient was

admitted to this facility after receiving

services in this facility's emergency

room department (CMS discontinued

this code 07/2010, although a small

number of claims with this code appear

after that time)

8 = Court/law enforcement — the patient

was admitted upon the direction of a

court of law or upon the request of a

law enforcement agency's

representative

9 = Information not available — how the

patient was admitted is not known

A = Reserved for national assignment. (eff.

3/08) Prior to 3/08 defined as: Transfer

from a critical access hospital — patient

was admitted/referred to this facility as

a transfer from a critical access hospital

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B = Transfer from another home health

agency — the patient was admitted

to this home health agency as a

transfer from another home health

agency. (Discontinued July 1, 2010

— Reference Condition Code 47)

C = Readmission to Same home health

Agency — the patient was

readmitted to this home health

agency within the same home

health episode period.

(Discontinued July 1, 2010)

D = Transfer from hospital inpatient in

the same facility resulting in a

separate claim to the payer — the

patient was admitted to this facility

as a transfer from hospital inpatient

within this facility resulting in a

separate claim to the payer

E = Transfer from ambulatory surgical

center

F = Transfer from hospice and is under a

hospice plan of care or enrolled in

hospice program

G = Transfer from a Designated Disaster

Alternate Care Site (eff. 7/2020)

For Newborn Type of Admission

1 = Normal delivery — a baby

delivered without complications

2 = Premature delivery — a baby

delivered with time and/or weight

factors qualifying it for premature

status

3 = Sick baby — a baby delivered with

medical complications, other than

those relating to premature status

4 = Extramural birth — a baby delivered in a

nonsterile environment

5 = Reserved for national assignment

6 = Reserved for national assignment

7 = Reserved for national assignment

8 = Reserved for national assignment

9 = Information not available

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 145

CLM_SRVC_CLSFCTN_TYPE_CD

LABEL: Claim Service Classification Type Code

DESCRIPTION: The type of service provided to the beneficiary.

SHORT NAME: TYPESRVC

LONG NAME: CLM_SRVC_CLSFCTN_TYPE_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: For facility type code 1 thru 6, and 9:

1 = Inpatient

2 = Inpatient or home health (covered

on Part B)

3 = Outpatient (or HHA — covered on

Part A)

4 = Other (Part B) — (includes HHA

medical and other health services,

e.g., SNF osteoporosis injectable

drugs)

5 = Intermediate care — level I

6 = Intermediate care — level II

7 = Subacute inpatient (revenue code 019X

required) (formerly Intermediate care

— level III)

8 = Swing bed

For facility type code 7 (clinics):

1 = Rural Health Clinic (RHC)

2 = Hospital based or independent

renal dialysis facility

3 = Free-standing provider based

federally qualified health center

(FQHC)

4 = Other Rehabilitation Facility (ORF)

5 = Comprehensive Rehabilitation Center

(CORF)

6 = Community Mental Health Center

(CMHC)

7 = Federally Qualified Health Center

(FQHC)

For facility type code 8 (special facility):

1 = Hospice (non-hospital based)

2 = Hospice (hospital based)

3 = Ambulatory surgical center (ASC) in

hospital outpatient department

4 = Freestanding birthing center

5 = Critical Access hospital — outpatient services

7 = Freestanding Non-residential Opioid Treatment

Programs (eff. 1/2021)

COMMENT: This field, in combination with the facility type code (variable called CLM_FAC_TYPE_CD) indicates the

“type of bill” for an institutional claim. Many different types of services can be billed on a Part A or

Part B institutional claim and knowing the type of bill helps to distinguish them. The type of bill is the

concatenation of two variables: the facility type (CLM_FAC_TYPE_CD) and the service classification

type code (CLM_SRVC_CLSFCTN_TYPE_CD). ^ Back to TOC ^

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CLM_SRVC_FAC_ZIP_CD

LABEL: Claim service facility ZIP code (where service was provided)

DESCRIPTION: ZIP code where service was provided, as indicated on the claim.

SHORT NAME: CLM_SRVC_FAC_ZIP_CD

LONG NAME: CLM_SRVC_FAC_ZIP_CD

TYPE: CHAR

LENGTH: 9

SOURCE: NCH

VALUES: XXXXXXXXX

COMMENT: —

^ Back to TOC ^

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CLM_SS_OUTLIER_STD_PYMT_AMT

LABEL: Claim Short Stay Outlier (SSO) Standard Payment Amount

DESCRIPTION: This variable is the standard payment amount for long-term care hospitals (LTCH) under the Medicare

prospective payment system (PPS), which is based on the MS-LTC-DRG with the short stay outlier

(SSO) adjustment.

This amount does not include any other applicable outlier payment amount.

SHORT NAME: CLM_SS_OUTLIER_STD_PYMT_AMT

LONG NAME: CLM_SS_OUTLIER_STD_PYMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: Applies only to inpatient (LTCH) claims. This field is new in October 2015.

For a LTCH PPS claim, only one of four fields will be populated (CLM_SITE_NTRL_PYMT_CST_AMT,

CLM_SITE_NTRL_PYMT_IPPS_AMT, CLM_FULL_STD_PYMT_AMT, or

CLM_SS_OUTLIER_STD_PYMT_AMT) as they are mutually exclusive (i.e., only one of the 4 fields will

have a non-zero value). The field with the non-zero value is included in the Claim Payment Amount

field.

^ Back to TOC ^

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CLM_THRU_DT

LABEL: Claim Through Date

DESCRIPTION: The last day on the billing statement covering services rendered to the beneficiary (a.k.a. “Statement

Covers Thru Date”).

SHORT NAME: THRU_DT

LONG NAME: CLM_THRU_DT

TYPE: DATE

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: For home health prospective payment system (PPS) claims, the “from” date and the “thru” date on the

RAP (Request for Anticipated Payment) initial claim match.

The "thru" date on the claim may not always represent the last date of services, particularly for home

health or hospice care. To obtain the date corresponding with the cessation of services (or discharge

date) use the discharge date from the claim (variable called NCH_BENE_DSCHRG_DT; NOTE: this

variable is not available for home health claims).

For Part B non-institutional (carrier and DME) services, this variable corresponds with the latest of any

of the line-item level dates (i.e., in the Line File, it is the last CLM_THRU_DT for any line on the claim).

It is almost always the same as the CLM_FROM_DT; exception is for DME claims — where some

services are billed in advance.

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CLM_TOT_CHRG_AMT

LABEL: Claim Total Charge Amount

DESCRIPTION: The total charges for all services included on the institutional claim.

This field is redundant with revenue center code 0001/total charges.

SHORT NAME: TOT_CHRG

LONG NAME: CLM_TOT_CHRG_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: —

^ Back to TOC ^

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CLM_TOT_PPS_CPTL_AMT

LABEL: Claim Total PPS Capital Amount

DESCRIPTION: The total amount that is payable for capital for the prospective payment system (PPS) claim.

This is the sum of the capital hospital specific portion, federal specific portion, outlier portion,

disproportionate share portion, indirect medical education portion, exception payments, and hold

harmless payments.

SHORT NAME: PPS_CPTL

LONG NAME: CLM_TOT_PPS_CPTL_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: Medicare payments are described in detail in a series of Medicare Payment Advisory Commission

(MedPAC) documents called “Payment Basics” (reference: https://www.medpac.gov/document-

type/payment-basic/).

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (reference:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/html/medicare-payment-systems.html).

^ Back to TOC ^

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CLM_TRTMT_AUTHRZTN_NUM

LABEL: Claim Treatment Authorization Number

DESCRIPTION: The number assigned by the medical reviewer and reported by the provider to identify the medical

review (treatment authorization) action taken after review of the beneficiary's case. It designates that

treatment covered by the bill has been authorized by the payer.

SHORT NAME: CLM_TRTMT_AUTHRZTN_NUM

LONG NAME: CLM_TRTMT_AUTHRZTN_NUM

TYPE: CHAR

LENGTH: 18

SOURCE: NCH

VALUES: XXXXXXX

COMMENT: This number is used by the fiscal intermediary and the Peer Review Organization.

^ Back to TOC ^

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CLM_UNCOMPD_CARE_PMT_AMT

LABEL: Claim Uncompensated Care Payment Amount

DESCRIPTION: This field identifies the payment for disproportionate share hospitals (DSH). It represents the

uncompensated care amount of the payment.

SHORT NAME: CLM_UNCOMPD_CARE_PMT_AMT

LONG NAME: CLM_UNCOMPD_CARE_PMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: This field applies only to inpatient claims.

These payments were authorized as part of Section 3133 of the Affordable Care Act (ACA).

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CLM_UTLZTN_DAY_CNT

LABEL: Claim Medicare Utilization Day Count

DESCRIPTION: On an institutional claim, the number of covered days of care that are chargeable to Medicare facility

utilization that includes full days, coinsurance days, and lifetime reserve days.

It excludes any days classified as non-covered, leave of absence days, and the day of discharge or

death.

SHORT NAME: UTIL_DAY

LONG NAME: CLM_UTLZTN_DAY_CNT

TYPE: NUM

LENGTH: 3

SOURCE: NCH

VALUES: —

COMMENT: —

^ Back to TOC ^

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CLM_VAL_AMT

LABEL: Claim Value Amount

DESCRIPTION: The amount related to the condition identified in the claim value code (variable called CLM_VAL_CD)

which was used by the intermediary to process the institutional claim.

SHORT NAME: VAL_AMT

LONG NAME: CLM_VAL_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: —

^ Back to TOC ^

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CLM_VAL_CD

LABEL: Claim Value Code

DESCRIPTION: The code indicating a monetary condition which was used by the intermediary to process an

institutional claim.

The associated monetary value is in the claim value amount field (CLM_VAL_AMT).

SHORT NAME: VAL_CD

LONG NAME: CLM_VAL_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES:

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01 = Most common semi-private rate

— to provide for the recording of

hospital's most common semi-

private rate

02 = Hospital has no semi-private

rooms — entering this code

requires $0.00 amount

03 = Reserved for national assignment

04 = Inpatient professional component

charges which are combined

billed — for use only by some all-

inclusive rate hospitals

05 = Professional component included

in charges and also billed

separately to carrier — for use on

Medicare and Medicaid bills if the

state requests this information

06 = Medicare blood deductible —

total cash blood deductible (Part

A blood deductible)

07 = Medicare cash deductible

reserved for national assignment

08 = Medicare Part A lifetime reserve

amount in first calendar year — lifetime

reserve amount charged in the year of

admission

09 = Medicare Part A coinsurance amount in

the first calendar year — coinsurance

amount charged in the year of

admission

10 = Medicare Part A lifetime reserve

amount in the second calendar year —

lifetime reserve amount charged in the

year of discharge where the bill spans

two calendar years

11 = Medicare Part A coinsurance amount in

the second calendar year —

coinsurance amount charged in the

year of discharge where the bill spans

two calendar years

12 = Amount is that portion of higher

priority EGHP insurance payment made

on behalf of aged bene provider applied

to Medicare covered services on this

bill. Six zeroes indicate provider claimed

conditional Medicare payment

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13 = Amount is that portion of higher

priority EGHP insurance payment

made on behalf of ESRD bene

provider applied to Medicare

covered services on this bill. Six

zeroes indicate the provider

claimed conditional Medicare

payment

14 = That portion of payment from

higher priority no fault auto/other

liability insurance made on behalf

of bene provider applied to

Medicare covered services on this

bill. Six zeroes indicate provider

claimed conditional payment

15 = That portion of a payment from a

higher priority WC plan made on

behalf of a bene that the provider

applied to Medicare covered

services on this bill. Six zeroes

indicate the provider claimed

conditional Medicare payment

16 = That portion of a payment from

higher priority PHS or other

federal agency made on behalf of

a bene the provider applied to

Medicare covered services on this

bill. Six zeroes indicate provider

claimed conditional Medicare

payment

17 = Operating outlier amount —

providers do not report this. For

payer internal use only. Indicates

the amount of day or cost outlier

payment to be made. (Do not

include any PPS capital outlier

payment in this entry)

18 = Operating disproportionate share

amount — providers do not report this.

For payer internal use only. Indicates

the disproportionate share amount

applicable to the bill. Use the amount

provided by the disproportionate share

field in PRICER. (Do not include any PPS

capital DSH adjustment in this entry)

19 = Inpatient use. Operating indirect

medical education amount — the A/B

MAC (A) reports operating indirect

medical education amount applicable. It

uses the amount provided by the

indirect medical education field in

PRICER. It does not include any PPS

capital IME adjustment in this entry

Outpatient use. The Medicare shared

system will display this payer only code

on the claim for low volume providers

to identify the amount of the low

volume adjustment being included in

the provider’s reimbursement. This

payer only code 19 is also used for IME

on hospital claims. This instruction shall

only apply to ESRD bill type 72x and

must not impact any existing

instructions for other bill types

20 = Total payment sent provider for capital

under PPS, including HSP, FSP, outlier,

old capital, DSH adjustment, IME

adjustment, and any exception amount

21 = Catastrophic — Medicaid — eligibility

requirements to be determined at state

level

22 = Surplus — Medicaid — eligibility

requirements to be determined at state

level

23 = Recurring monthly income — Medicaid —

eligibility requirements to be determined

at state level

24 = Medicaid rate code — Medicaid —

eligibility requirements to be determined

at state level

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25 = Offset to the patient payment

amount (prescription drugs) —

prescription drugs paid for out of

a long-term care facility

resident/patient's fund in the

billing period submitted

(statement covers period)

26 = Prescription drugs offset to

patient (payment amount —

hearing and ear services) hearing

and ear services paid for out of a

long-term care facility

resident/patient's funds in the

billing period submitted

(statement covers period)

27 = Offset to the patient (payment

amount — vision and eye

services) — vision and eye

services paid for out of a long-

term care facility

resident/patient's funds in the

billing period submitted

(statement covers period)

28 = Offset to the patient (payment

amount — dental services) —

dental services paid for out of a

long-term care facility

resident/patient's funds in the

billing period submitted

(statement covers period)

29 = Offset to the patient (payment

amount — chiropractic services)

— chiropractic services paid for

out of a long-term care facility

resident/patient's funds in the

billing period submitted

(statement covers period)

30 = Preadmission testing — the code

used to reflect the charges for

preadmission outpatient

diagnostic services in preparation

for a previously scheduled

admission

31 = Patient liability amount — amount

shown is that which you or the PRO

approved to charge the bene for non-

covered accommodations, diagnostic

procedures, or treatments

32 = Multiple patient ambulance transport

— the number of patients

transported during one ambulance

ride to the same destination. (eff.

4/2003)

33 = Offset to the patient payment

amount (podiatric services) —

podiatric services paid out of a long-

term care facility resident/patient's

funds in the billing period submitted

34 = Offset to the patient payment

amount (medical services) — other

medical services paid out of a long-

term care facility resident/patient's

funds in the billing period submitted

35 = Offset to the patient payment

amount (health insurance premiums)

— other medical services paid out of

a long-term care facility resident/

patient's funds in the billing period

submitted

37 = Pints of blood furnished — total

number of pints of whole blood or

units of packed red cells furnished to

the patient

38 = Blood deductible pints — the number

of unreplaced pints of whole blood or

units of packed red cells furnished for

which the patient is responsible

39 = Pints of blood replaced — the total

number of pints of whole blood or

units of packed red cells furnished to

the patient that have been replaced

by or on behalf of the patient

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40 = New coverage not implemented

by HMO — amount shown is for

inpatient charges covered by

HMO. (use this code when the bill

includes inpatient charges for

newly covered services which are

not paid by HMO

41 = Amount is that portion of a

payment from higher priority BL

program made on behalf of bene

the provider applied to Medicare

covered services on this bill. Six

zeroes indicate the provider

claimed conditional Medicare

payment

42 = VA or PACE

43 = Disabled bene under age 65 with

LGHP — amount is that portion of

a payment from a higher priority

LGHP made on behalf of a

disabled Medicare bene the

provider applied to Medicare

covered services on this bill

44 = Amount provider agreed to

accept from primary payer when

amount less than charges, but

more than payment received —

when a lesser amount is received

and the received amount is less

than charges, a Medicare

secondary payment is due

45 = Accident hour — the hour the

accident occurred that

necessitated medical treatment

46 = Number of grace days —

following the date of the

PRO/UR determination, this is

the number of days

determined by the PRO/UR to

be necessary to arrange for

the patient's post-discharge

care

47 = Any liability insurance — amount is that

portion from a higher priority liability

insurance made on behalf of Medicare

bene the provider is applying to

Medicare covered services on this bill

48 = Hemoglobin reading — the patient's

most recent hemoglobin reading taken

before the start of the billing period

(eff. 1/2006). Prior to 1/2006 defined

as the latest hemoglobin reading taken

during the billing cycle

49 = Hematocrit reading — the patient's

most recent hematocrit reading taken

before the start of the billing period

(eff. 1/2006). Prior to 1/2006 defined

as hematocrit reading taken during the

billing cycle

50 = Physical therapy visits — indicates the

number of physical therapy visits from

onset (at billing provider) through this

billing period

51 = Occupational therapy visits —

indicates the number of occupational

therapy visits from onset (at the billing

provider) through this billing period

52 = Speech therapy visits — indicates the

number of speech therapy visits from

onset (at billing provider) through this

billing period

53 = Cardiac rehabilitation — indicates the

number of cardiac rehabilitation visits

from onset (at billing provider)

through this billing period

54 = New birth weight in grams — actual

birth weight or weight at time of

admission for an extramural birth.

Required on all claims with type of

admission of “4” and on other claims as

required by law

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55 = Eligibility threshold for charity

care — code identifies the

corresponding value amount at

which a health care facility

determines the eligibility

threshold of charity care

56 = Hours skilled nursing provided —

the number of hours skilled

nursing provided during the billing

period. Count only hours spent in

the home

57 = Home health visit hours — the

number of home health aide

services provided during the

billing period. Count only the

hours spent in the home

58 = Arterial blood gas — arterial

blood gas value at beginning of

each reporting period for oxygen

therapy. This value or value 59

will be required on the initial bill

for oxygen therapy and on the

fourth month's bill

59 = Oxygen saturation — oxygen

saturation at the beginning of

each reporting period for oxygen

therapy. This value or value 58

will be required on the initial bill

for oxygen therapy and on the

fourth month's bill

60 = HHA branch MSA — MSA in which

HHA branch is located

61 = Location of HHA service or hospice

service — the Balanced Budget Act

(BBA) requires that the geographic

location of where the service was

provided be furnished instead of the

geographic location of the provider.

NOTE: HHA claims with a thru date on

or before 12/2005, the value code

amount field reflects the MSA code

(followed by zeroes to fill the field).

HHA claims with a thru date after

12/2005, the value code amount field

reflects the CBSA code

62 = Payer only — on type of bill 032x: HH

visits Part A — the number of visits

determined by Medicare to be

payable from the Part A Trust Fund to

reflect the shift of payments from the

Part A to the Part B Trust Fund as

mandated by §1812(a)(3) of the Social

Security Act. On type of bills 081x or

082x: Number of high routine home

care days — days that fall within the

first 60 days of a routine home care

hospice claim)

63 = Payer only — on type of bill 032x: HH

visits — Part B — the number of visits

determined by Medicare to be

payable from the Part B trust fund to

reflect the shift of payments from the

Part A to the Part B Trust Fund as

mandated by §1812(a)(3) of the Social

Security Act. On type of bills 081x or

082x: Number of low routine home

care days — days that come after the

first 60 days of a routine home care

hospice claim

64 = Payer only HH reimbursement — Part

A — the dollar amounts determined

to be associated with the HH visits

identified in a value code 62 amount.

This Part A payment reflects the shift

of payments from the Part A to the

Part B Trust Fund as mandated by

§1812(a)(3) of the Social Security Act.

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65 = Payer only HH reimbursement —

Part B — the dollar amounts

determined to be associated

with the HH visits identified in a

value code 63 amount. This Part

B payment reflects the shift of

payments from the Part A to the

Part B Trust Fund as mandated

by 1812(a)(3) of the Social

Security Act

66 = Medicare spend-down amount

— the dollar amount that was

used to meet the recipient's

spend-down liability for this

claim

67 = Peritoneal dialysis — the

number of hours of peritoneal

dialysis provided during the

billing period (only the hours

spent in the home)

68 = EPO drug — number of units of

EPO administered relating to the

billing period

69 = State charity care percent — code

indicates the percentage of

charity care eligibility for the

patient

70 = Interest amount — (providers do

not report this.) Report the

amount applied to this bill

71 = Funding of ESRD networks —

(providers do not report this.)

Report the amount the Medicare

payment was reduced to help

fund the ESRD networks

72 = Flat rate surgery charge — code

indicates the amount of the

charge for outpatient surgery

where the hospital has such a

charging structure

73 = Sequestration adjustment amount

74 = Low volume hospital payment amount

75 = Prior covered days for an interrupted

stay

76 = Provider’s interim rate — report

provider's percentage of billed

charges interim rate during billing

period. Applies to OP hospital, SNF

and HHA claims where interim rate is

applicable. Report to left of

dollar/cents delimiter. (TP payers

internal use only). An interim rate of

50 percent is entered as follows:

50.00

77 = New technology add-on payment

amount — amount of payments made

for discharges involving approved new

technologies. If the total covered costs

of the discharge exceed the DRG

payment for the case (including

adjustments for IME and

disproportionate share hospitals (DSH)

but excluding outlier payments) an add-

on amount is made indicating a new

technology was used in the treatment of

the beneficiary. (eff. 4/2003, under

inpatient PPS)

78 = Off-site zip code — when the facility zip

(Loop 2310E N403 Segment) is present

for the following bill types: 012X, 013X,

014X, 022X, 023X, 034X, 072X, 074X,

075X, 081X, 082X, and 085X. The ZIP

code is associated with this value and is

used to price MPFS HCPCS and

anesthesia services for CAH Method II

79 = Total payments for services applicable to

the ESRD — the Medicare shared system

will display this payer only code on the

claim. The value represents the dollar

amount for Medicare allowed payments

applicable for the calculation in

determining an outlier payment

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80 = Covered days — the number of

days covered by the primary

payer

81 = Non-covered days — days of

care not covered by the primary

payer

82 = Coinsurance days — the

inpatient Medicare days

occurring after the 60th day and

before the 91st day or inpatient

SNF/swing bed days occurring

after the 20th and before the

101st day in a single spell of

illness

83 = Lifetime reserve days — under

Medicare, each beneficiary has a

lifetime reserve of 60 additional

days of inpatient hospital

services after using 90 days of

inpatient hospital services during

a spell of illness

84 = Medicare lifetime reserve amount

— in the third or greater calendar

years (eff. 1/2013

85 = Medicare coinsurance amount in

the third or greater calendar years

(eff. 1/2013)

86 = Invoice cost (for CAR T-cells) (eff.

04/2019, term. 3/2020)

87 = Gene therapy invoice cost (eff.

4/2020)

88 = Allogeneic stem cell transplant —

number of related donors’

evaluation (eff. 7/2020)

89 = Allogeneic stem cell transplant —

total all-inclusive donor charges

(eff. 7/2020)

90 = Cell therapy invoice cost (eff.

4/2020)

91 = Charges for kidney acquisition (eff.

10/2021)

92–99 = Reserved for national assignment

A0 = Special zip code reporting — five-digit

zip code of the location from which the

beneficiary is initially placed on board

the ambulance (eff. 9/2001)

A1 = Deductible payer A — the amount

assumed by the provider to be applied

to the patient's deductible amount to

the involving the indicated payer. (eff.

10/1993) — prior value 0

A2 = Coinsurance payer A — the amount

assumed by the provider to be applied

to the patient's Part B coinsurance

amount involving the indicated payer

A3 = Estimated responsibility payer A — the

amount estimated by the provider to be

paid by the indicated payer

A4 = Self-administered drugs administered in

an emergency situation — ordinarily the

only non-covered self-administered drug

paid for under Medicare in an

emergency situation is insulin

administered to a patient in a diabetic

coma

A5 = Covered self-administered drugs — the

amount included in covered charges for

self-administrable drugs administered to

the patient because the drug was not

self-administered in the form and

situation in which it was furnished to the

patient

A6 = Covered self-administered drugs —

diagnostic study and other — the

amount included in covered charges for

self-administrable drugs administered to

the patient because the drug was

necessary for diagnostic study or other

reasons. For use with revenue center

0637

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A7 = Copayment A — the amount

assumed by the provider to be

applied toward the patient's

copayment amount involving the

indicated payer

A8 = Patient weight — weight of

patient in kilograms. Report this

data only when the health plan

has a predefined change in

reimbursement that is affected by

weight

A9 = Patient height — height of

patient in centimeters. Report

this data only when the health

plan has a predefined change in

reimbursement that is affected by

height

AA = Regulatory surcharges,

assessments, allowances or

health care related taxes (payer

A) — the amount of regulatory

surcharges, assessments,

allowances, or health care related

taxes pertaining to the indicated

payer (eff. 10/2003)

AB = Other assessments or allowances

(payer A) — the amount of other

assessments or allowances

pertaining to the indicated payer

(eff. 10/2003)

B1 = Deductible payer B — the amount

assumed by the provider to be

applied to the patient's deductible

amount involving the indicated

payer (eff. 10/1993) — prior value

B2 = Coinsurance payer B — the

amount assumed by the provider

to be applied to the patient's Part

B coinsurance amount involving

the indicated payer

B3 = Estimated responsibility payer B —

the amount estimated by the

provider to be paid by the indicated

payer

B7 = Copayment B — the amount

assumed by the provider to be

applied toward the patient's

copayment amount involving the

indicated payer

BA = Regulatory surcharges, assessments,

allowances or health care related

taxes (payer B) — the amount of

regulatory surcharges, assessments,

allowances, or health care related

taxes pertaining to the indicated

payer (eff. 10/2003)

BB = Other assessments or allowances

(payer B) — the amount of other

assessments or allowances

pertaining to the indicated payer.

(eff. 10/2003)

C1 = Deductible payer C — the amount

assumed by the provider to be

applied to the patient's deductible

amount involving the indicated

payer. (eff. 10/1993) — prior value

C2 = Coinsurance payer C — the amount

assumed by the provider to be

applied to the patient's Part B

coinsurance amount involving the

indicated payer

C3 = Estimated responsibility payer C

C7 = Copayment C — the amount

assumed by the provider to be

applied toward the patient's

copayment amount involving the

indicated payer

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CA = Regulatory surcharges,

assessments, allowances or

health care related taxes (payer

C) — the amount of regulatory

surcharges, assessments,

allowances, or health care

related taxes pertaining to the

indicated payer (eff. 10/2003)

CB = Other assessments or

allowances (payer C) — the

amount of other assessments or

allowances pertaining to the

indicated payer (eff. 10/2003)

D3 = Estimated responsibility patient

— the amount estimated by the

provider to be paid by the

indicated patient

D4 = Clinical trial number assigned by

NLM/NIH — eight-digit numeric

National Library of

Medicine/National Institute of

Health clinical trial registry

number or a default number of

“99999999” if the trial does not

have an 8-digit registry number.

(eff. 10/2007)

D5 = Result of last Kt/V. For in-center

hemodialysis patients, this is the

last reading taken during the

billing period. For peritoneal

dialysis patients (and home

hemodialysis patients), this may

be before the current billing

period but should be within 4

months of the date of service (eff.

7/1/10)

D6 = Total number of minutes of

dialysis provided during the billing

period (eff. 1/2021)

E1 = Deductible payer D

E3 = Estimated responsibility payer D

F1 = Deductible payer E

F2 = Coinsurance payer E

F3 = Estimated responsibility payer E

FC = Patient paid amount — the amount the

provider has received from the patient

toward payment of this bill (7/2008)

FD = Credit received from the manufacturer

for a replaced medical device — the

amount the provider has received from a

medical device manufacturer as credit

for a replaced device. (eff. 7/2008)

G1 = Deductible payer F

G2 = Coinsurance payer F

G3 = Estimated responsibility payer F

G8 = Facility where inpatient hospice service

is delivered — MSA or Core Based

Statistical Area (CBSA) number (or rural

state code) of the facility where

inpatient hospice is delivered. (eff.

1/2008)

GA = Regulatory surcharges, assessments,

allowances or health care related taxes

payer F

P0 = Reserved for public health data reporting

P1 = Heart rate (eff. 7/2019)

P2 = Blood pressure — systolic (eff. 7/2019)

P3 = Blood pressure — diastolic (eff. 7/2019)

Q0 = Represents the amount Medicare would

have paid prior to the Model reduction

Q1 = Represents the actual Model reduction

amount

Q2 = Hospice claim paid from Part B Trust Fund

Q3 = Prior authorization 25% penalty

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Q4 = Pennsylvania (PA) rural health

exclusion — physician services

claim reimbursement

Q5 = Electronic health record (EHR)

reduction

Q6 = PQRS

Q7 = Islet add-on payment amount

(eff. 10/2016)

Q8 = Total transitional drug add-on

payment adjustment (TDAPA)

amount (eff. 1/2018)

Q9 = Medicare Advantage (MA) plan

amount (eff. 10/2014)

QA = PHP partial week input

QB = ESRD Treatment Choices (ETC)

Model: Home Dialysis Payment

Adjustment (HDPA) total bonus

paid

QC = OCM+ payment adjustment

amount (payer only) — (eff.

1/2020)

QD = Device credit

QE = ET3 Model – ET3 15% bonus

payment

QF = HHA — LATE-SUB-PENALTY-AMT

QG = Total Transitional Add-on

Payment Adjustment for New

and Innovative Equipment and

Supplies (TPNIES) amount —

used to capture the add-on

payment (eff. 4/2021)

QH = Total TPNIES CRA amount —

used to capture the add-on

payment. (payer only) (eff.

1/2022)

QI = Maryland Primary Care Program

(MDPCP) Federally Qualified Health

Center (FQHC) demo — used to

capture reduction amounts (payer

only) (eff. 1/2022)

QJ = ESRD treatment choices (ETC)

facility performance payment

adjustment (PPA) (payer only) (eff.

7/2022)

QK = Maryland waiver kidney acquisition

payment

QM = MIPS adjustment amount

QN = First APC pass-through device

offset

QO = Second APC pass-through device

offset

QP = Reserved for future use

QQ = Terminated procedure with pass-

through device OR condition for

device credit present

QR = First APC pass-through drug or

biological offset

QS = Second APC pass-through drug or

biological offset

QT = Third APC pass-through drug or

biological offset

QU = Device credit with device offset

QV = Value based purchasing adjustment

amount

QW = PHP partial week output

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XX = Total charge amount for all Part A

visits on RIC “U” claims — for

home health claims containing

both Part A and Part B services

this code identifies the total

charge amount for the Part A

visits (based on revenue center

codes 042X, 043X, 044X, 055X,

056X, and 057X). Code created

internally in the NCHMQA

system (eff. 10/2001 with

HHPPS)

XY = Total charge amount for all Part B

visits on RIC “U” claims — for

home health claims containing

both Part A and Part B services

this code identifies the total

charge amount for the Part B

visits (based on revenue center

codes 042X, 043X, 044X, 055X,

056X, and 057X). Code created

internally in the NCHMQA system

(eff. 10/2001 with HHPPS)

XZ = Total charge amount for all Part B

non-visit charges on the RIC “U”

claims — for home health claims

containing both Part A and Part B

services, this code identifies the

total charge amount for the Part

B non-visit charges. Code created

internally in the NCHMQA system

(eff. 10/2001 with HHPPS)

Y1 = Part A demo payment — portion

of the payment designated as

reimbursement for Part A services

under the demonstration.

Amount instead of the traditional

prospective DRG payment

(operating and capital) as well as

any outlier payments that might have

been applicable in the absence of the

demonstration. No deductible or

coinsurance has been applied.

Payments for operating IME and DSH

processed traditionally are also not

included in this amount

Y2 = Part B demo payment — portion

of the payment designated as

reimbursement for Part B services

under the demonstration. No

deductible or coinsurance has

been applied

Y3 = Part B coinsurance — amount of

Part B coinsurance applied by the

intermediary to this demo claim.

For demonstration claims this will

be a fixed copayment unique to

each hospital and DRG (or

DRG/procedure group)

Y4 = Conventional provider payment

amount for non-demonstration

claims — this the amount Medicare

would have reimbursed the provider

for Part A services if there had been

no demonstration. This should

include the prospective DRG

payment (both capital as well as

operational) as well as any outlier

payment, which would be applicable.

It does not include any pass-through

amounts such as that for direct

medical education nor interim

payments for operating IME and DS

Y5 = Part B deductible, applicable for a model 4

demonstration 64 claims

Z9 = COVID-19 PHE end date

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 167

CLM_VBP_ADJSTMT_PCT

LABEL: Claim VBP Adjustment Percent

DESCRIPTION: Under the Hospital Value Based Purchasing (HVBP) program, an adjustment is made to the base

operating DRG amount for certain inpatient prospective payment system (IPPS) hospitals — based on

their total performance score (TPS).

SHORT NAME: CLM_VBP_ADJSTMT_PCT

LONG NAME: CLM_VBP_ADJSTMT_PCT

TYPE: NUM

LENGTH: 15

SOURCE: NCH

VALUES: X.XX

COMMENT: This initiative began in fourth quarter of 2013 (i.e., beginning of federal fiscal year 14 [FY14]).

This field was new in 2013 and is null/missing for all previous years.

The HVBP applies only to subsection (d) IPPS hospitals. There is a variable that indicates whether the

hospital was excluded from HVBP (reference CLM_VBP_PRTCPNT_IND_CD). This percentage reduction

is applied to the base operating DRG amount, depending on their TPS (which is the Value Based

Purchasing Score), as required by the Affordable Care Act (ACA). The percentages change each FY.

Additional information is available on the CMS "Hospital Value-Based Purchasing" website.

The actual dollar amount of the adjustment that applied to the claim is found in the variable called

CLM_VBP_ADJSTMT_PMT_AMT.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 168

CLM_VBP_ADJSTMT_PMT_AMT

LABEL: Claim Value-Based Purchasing Adjustment Payment Amount

DESCRIPTION: This field represents the Hospital Value Based Purchasing (HVBP) amount.

This could be an additional payment on the claim or a reduction, depending on the hospital's

performance score.

SHORT NAME: CLM_VBP_ADJSTMT_PMT_AMT

LONG NAME: CLM_VBP_ADJSTMT_PMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX (may be a negative value)

COMMENT: This initiative began in fourth quarter of 2013 (i.e., beginning of federal fiscal year 14 [FY14]). This field

was new in 2013 and is null/missing for all previous years.

The HVBP applies only to subsection (d) inpatient prospective payment system (IPPS) hospitals. There

is a variable that indicates whether the hospital was excluded from HVBP (reference

CLM_VBP_PRTCPNT_IND_CD).

This amount is based on a VBP adjustment percent (variable called CLM_VBP_ADJSTMT_PCT) that is

applied to the base operating DRG amount, depending on the hospital's Total Performance Score

(TPS), which is the Value Based Purchasing Score.

HVBP is required by the Affordable Care Act (ACA). The percentages change each FY. Additional

information is available on the CMS "Hospital Value-Based Purchasing" website.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 169

CLM_VBP_PRTCPNT_IND_CD

LABEL: Claim Value-Based Purchasing (VBP) Participant Indicator Code

DESCRIPTION: This field is the code used to identify a reason a hospital is excluded from the Hospital Value Based

Purchasing (HVBP) program.

SHORT NAME: CLM_VBP_PRTCPNT_IND_CD

LONG NAME: CLM_VBP_PRTCPNT_IND_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: Y = Participating in Hospital Value Based Purchasing

N = Not participating in Hospital Value Based Purchasing

Null/missing = same as “N”

COMMENT: The ACA (Section 3001) excludes from the HVBP hospitals that meet certain conditions. Additional

information is available on the CMS "Hospital Value-Based Purchasing" website.

This initiative began in fourth quarter of 2013 (i.e., beginning of federal fiscal year 14).

This field was new in 2013, and is null/missing for all previous years.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 170

CPO_ORG_NPI_NUM

LABEL: CPO Organization NPI Number

DESCRIPTION: The National Provider Identifier (NPI) number of the home health agency (HHA) or hospice rendering

Medicare services during the period the physician is providing care plan oversight (CPO).

SHORT NAME: CPO_ORG_NPI_NUM

LONG NAME: CPO_ORG_NPI_NUM

TYPE: CHAR

LENGTH: 10

SOURCE: NCH

VALUES: —

COMMENT: The purpose of this field is to ensure compliance with the CPO requirement that the beneficiary must

be receiving covered HHA or hospice services during the billing period. There can be only one CPO

provider number per claim, and no other services but CPO physician services are to be reported on the

claim. This field is only present on the non-DMERC processed carrier claim.

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CPO_PRVDR_NUM

LABEL: Care Plan Oversight (CPO) Provider Number

DESCRIPTION: The National Provider Identifier (NPI) number of the home health agency (HHA) or hospice rendering

Medicare services during the period the physician is providing care plan oversight (CPO).

SHORT NAME: CPO_PRVDR_NUM

LONG NAME: CPO_PRVDR_NUM

TYPE: CHAR

LENGTH: 10

SOURCE: NCH

VALUES: —

COMMENT: The purpose of this field is to ensure compliance with the CPO requirement that the beneficiary must

be receiving covered HHA or hospice services during the billing period. There can be only one CPO

provider number per claim, and no other services but CPO physician services are to be reported on the

claim. This field is only present on the non-DMERC processed carrier claim.

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 172

DEMO_ID_NUM

LABEL: Demonstration number

DESCRIPTION: The number assigned to identify a CMS demonstration project.

This field is also used to denote special processing (a.k.a. special processing number, SPN).

SHORT NAME: DEMO_ID_NUM

LONG NAME: DEMO_ID_NUM

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES:

01 = Nursing Home Case-Mix and

Quality Demo

02 = National HHA Prospective

Payment Demo

03 = Telemedicine Waiver Demo

(retired)

04 = United Mine Workers of America

(UMWA) Managed Care Demo

05 = Medicare Choices (MCO

encounter data) demo

06 = Medicare Participating Heart

Bypass Center Demo

07 = Participating Centers of

Excellence (retired)

08 = Provider Partnership Demo

(retired) 09 = Colorado Integrated

Care and Financing Project

10 = Community Nursing Organization

Demo

11 = Consumer Directed DME Demo

12 = Competitive Bidding for Clinical

Labs (non-MMA demo)

13 = Competitive Bidding for DME

Demo

14 = Competitive Pricing — open

enrollment demo (non-MMA)

15 = ESRD Managed Care (MCO

encounter data) demo (retired

16 = Utah All Payer

Graduate Medical

Education demo

17 = Group Specific Volume Performance

Standards

19 = Medicaid Working Group Dual

eligibles

20 = Minnesota Senior Health options

21 = Municipal Health Services Program

22 = New England Dual Eligible Waiver

Project

23 = PACE

24 = Seattle Outlier Pool

25 = SHMO II

26 = VA Medicare Subvention Demo

27 = Wisconsin Partnership Demo

29 = On Lok

30 = Lung Volume Reduction (NIH

Clinical Trial) non-demo

31 = VA Pricing — not a demo

32 = DoD Medicare Subvention Demo

33 = Medical Savings Account (BBA)

34 = New York Continuing Care Networks

(aka Rochester and Monroe County)

35 = Evercare Managed Care for Nursing

Home Residents

36 = SHMO I

37 = Coordinated Care Demonstration

(BBA)

38 = Encounter Data (not a demo)

39 = Flu/Pneumonia vaccinations

Encounter Data

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40 = Payment of Physician and Non-

physician Services in certain

Indian Providers (Rhem Gray)

42 = ESRD DM — basic

ESRD demo bundle

43 = ESRD DM — expanded ESRD

demo bundle including venous

access procedures

44 = Homebound demo (MMA)

45 = Chiropractic (MMA)

46 = Vision Rehab (2004 appropriation

project)

47 = Flu Medication Demo

48 = Home health Adult Day-Care (s.

703 of MMA)

49 = Frequent Hemodialysis Network

Clinical Trial

50 = Anti-Cancer Colorectal Drugs

during Clinical Trials

51 = Clinical Lab Competitive Bidding

(MMA) (retired)

52 = Inhalation Therapy (retired)

53 = Frontier Extended Stay Clinic

54 = ACE Demo (retired)

55 = Avastin Lucentis Clinical trial

56 = Section 3113 ACA Lab Demo

(retired)

57 = Medicaid Emergency Psych —

section 2707 ACA

58 = Multi-payer Advanced Primary

Care Practice (MAPCP) CMMI

59 = Pioneer ACO Model (CMI)

60 = Medicare Pre-Payment Review

and Prior Authorization of Power

Mobility Devices Demonstration

(OFM) (retired 1/2023)

61 = Bundled Payments for Care

Improvement model 1 (CMMI)

62 = Bundled Payments for Care

Improvement model 2

63 = Bundled Payments for Care

Improvement model 3

64 = Bundled Payments for Care

Improvement model 4

65 = A/B Rebilling Demonstration —

rebilled claims due to auditor

denials (OFM) (retired 1/2023)

66 = A/B Rebilling Demonstration —

rebilled claims due to provider self-

audit after claims

submission/payment (retired 1/2023)

67 = A/B Rebilling Demonstration — rebilled

claims due to provider self-audit after

the patient has been discharged but

prior to payment (retired 1/2023)

68 = SNF Qualifying Stay — Pioneer ACO

69 = Advance Payment ACO Model

70 = Electrical Workers Insurance Fund claims

(EWIF)

71 = IVIG (Intravenous Immunoglobulin)

Demo

72 =Implementing Payment Changes for

home health Travel Reimbursement

Changes for FCHIP.

73 = Medicare Care Choices Model

74 = Next Generation ACO Model

75 = Coordinated Quality Care —

Comprehensive Care for Joint

replacement (CCJR)

76 = Million Hearts CVD Risk Reduction

Model

77 = Shared Savings Program (used in FISS

and CWF to bypass the SNF 3-day

requirement)78 = Comprehensive

Primary Care Plus (CPC+) Model — MCS

analysis

79 = Acute Myocardial Infarction (AMI)

Episode Payment Model (EPM)

80 = Coronary Artery Bypass Graft (CABG)

Episode Payment Model (EPM)

81 = Surgical Hip and Femur Fracture

Treatment (SHFFT) Episode Payment

Model (EMP)

82 = Medicare Diabetes Prevention

Program (MDPP)

83 = Maryland Primary Care Program

(MDPCP) Federally Qualified Health

Center (FQHC) (eff. 1/2022).

Previously was Maryland All Payer

Model. This is the 3rd iteration of

the Maryland All-Payer Model. This

latest iteration encompasses

Maryland Primary Care Program

(MDPCP)

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84 = Diabetes Prevention Program

Virtual Model Test

85 = Comprehensive ESRD Care (CEC)

Model

86 = Bundled Payments for Care

Improvement (BPCI) —

Advanced

87 = Radiation Oncology Bundled

Payments

88 = Shared Savings Program

(TELEHEALTH waiver)

89 = Vermont all-payer (VT ACO

model)

91 = Emergency Triage, Treat and

Transport (ET3)

92 = Direct Contracting (DC) Model/

ACO reach (delete)

93 = Comprehensive Kidney Care

Contracting (CKCC)

94 = ESRD Treatment Choices (ETC)

95 = Oncology Care Model Plus

(OCM+)

96 = Primary Care First (PCF) Seriously

Ill Population (SIP) Model

97 = Kidney Care First (KCF)

98 = The Pennsylvania Rural Health

Model (PARHM)

99 = Opioid Use Disorder (OUD)

Treatment Demonstration

Program

A1 = Direct contracting (GEO)

A2 = Community Health Access and

Rural Transformation Model

(CHART)

A3 = Enhancing Oncology Model

A4 = Maryland Total Cost of Care Model

A5 = Making Care Primary (MCP) claims

A6= Guiding an Improved Dementia

Experience

COMMENT: —

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 175

DEMO_ID_SQNC_NUM

LABEL: Demonstration sequence number

DESCRIPTION: The number of demonstration identification trailers present on the claim.

SHORT NAME: DEMO_ID_SQNC_NUM

LONG NAME: DEMO_ID_SQNC_NUM

TYPE: NUM

LENGTH: 3

SOURCE: CCW

VALUES: —

COMMENT: The demonstration sequence number is a sequential line number to distinguish distinct demonstration

projects that affect the same claim.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 176

DEMO_INFO_TXT

LABEL: Demonstration information text

DESCRIPTION: This is a text field that contains information related to the demonstration.

For example, a claim involving a CHOICES demo id “05” would contain the MCO plan contract number

in the first five positions of this text field.

SHORT NAME: DEMO_INFO_TXT

LONG NAME: DEMO_INFO_TXT

TYPE: CHAR

LENGTH: 15

SOURCE: NCH

VALUES: —

COMMENT: When the Demo ID = 01 (RUGS) — the text field will contain a 2, 3 or 4 to denote the RUGS phase. If

RUGS phase is blank or not one of the above the text field will reflect “INVALID”. NOTE: In version “G”,

RUGS phase was stored in redefined Claim Edit Group, 3rd occurrence, 4th position.

Demo ID = 02 (home health demo) — the text field will contain PROV#. When demo number not equal

to 02 then text will reflect “INVALID”

Demo ID = 03 (Telemedicine demo) — text field will contain the HCPCS code. If the required HCPCS is

not shown, then the text field will reflect “INVALID”

Demo ID = 04 (UMWA) — text field will contain W0 denoting that condition code W0 was present. If

condition code W0 not present, then the text field will reflect “INVALID”

Demo ID = 05 (CHOICES) — the text field will contain the CHOICES plan number, if both of the

following conditions are met: (1) CHOICES plan number present and PPS or inpatient claim shows that

1st 3 positions of provider number as “210” and the admission date is within HMO

effective/termination date; or non-PPS claim and the from date is within HMO effective/termination

date and (2) CHOICES plan number matches the HMO plan number. If either condition is not met the

text field will reflect “INVALID CHOICES PLAN NUMBER”. When CHOICES plan number not present,

text will reflect “INVALID”

Demo ID = 15 (ESRD Managed Care) — text field will contain the ESRD/MCO plan number. If

ESRD/MCO plan number does not present the field will reflect “INVALID”

Demo ID = 38 (Physician Encounter Claims) — text field will contain the MCO plan number. When

MCO plan number is not present the field will reflect “INVALID”

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 177

DMERC_LINE_FRGN_ADR_IND

LABEL: Line Foreign Address Indicator

DESCRIPTION: Line Foreign Address Indicator on the durable medical equipment (DME) claim line

SHORT NAME: DMERC_LINE_FRGN_ADR_IND

LONG NAME: DMERC_LINE_FRGN_ADR_IND

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES: EX = Expatriate Beneficiary

COMMENT: This field is used to identify claims for expatriate beneficiaries (beneficiary whose permanent address

is outside the U.S.) who purchased DMEPOS items that were furnished in the United States.

This field was new in July 2016.

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 178

DMERC_LINE_MTUS_CD

LABEL: DMERC Line Miles/Time/ Units/Services (MTUS) Indicator Code

DESCRIPTION: Code indicating the units associated with services needing unit reporting on the line item for the

DMERC service.

SHORT NAME: UNIT_IND

LONG NAME: DMERC_LINE_MTUS_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: 0 = Values reported as zero

1 = (rarely used)

2 = (rarely used)

3 = Number of services

4 = Oxygen volume units

6 = Drug dosage (valid 2004 and earlier) — since early 1994 this value has incorrectly been placed on

DMERC claims. The DMERCs were overriding the MTUS indicator with a “6” if the claim was

submitted with an NDC code.

NOTE: This problem has been corrected — no date on when the correction became effective.

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 179

DMERC_LINE_MTUS_CNT

LABEL: DMERC Line Miles/Time/Units/Services (MTUS) Count

DESCRIPTION: The count of the total units associated with services needing unit reporting such as number of

supplies, volume of oxygen or nutritional units.

This is a line-item field on the DMERC claim and is used for both allowed and denied services.

SHORT NAME: DME_UNIT

LONG NAME: DMERC_LINE_MTUS_CNT

TYPE: NUM

LENGTH: 11

SOURCE: NCH

VALUES: —

COMMENT: Prior to version “J,” this field was S9(3)

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 180

DMERC_LINE_PRCNG_STATE_CD

LABEL: DMERC Line Pricing State Code (SSA)

DESCRIPTION: The 2-digit SSA state code where the durable medical equipment (DME) supplier was located; used by

the Medicare Administrative Contractor (MAC) for pricing the service.

SHORT NAME: PRCNG_ST

LONG NAME: DMERC_LINE_PRCNG_STATE_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES:

01 = Alabama

02 = Alaska

03 = Arizona

04 = Arkansas

05 = California

06 = Colorado

07 = Connecticut

08 = Delaware

09 = District of Columbia

10 = Florida

11 = Georgia

12 = Hawaii

13 = Idaho

14 = Illinois

15 = Indiana

16 = Iowa

17 = Kansas

18 = Kentucky

19 = Louisiana

20 = Maine

21 = Maryland

22 = Massachusetts

23 = Michigan

24 = Minnesota

25 = Mississippi

26 = Missouri

27 = Montana

28 = Nebraska

29 = Nevada

30 = New Hampshire

31 = New Jersey

32 = New Mexico

33 = New York

34 = North Carolina

35 = North Dakota

36 = Ohio

37 = Oklahoma

38 = Oregon

39 = Pennsylvania

40 = Puerto Rico

41 = Rhode Island

42 = South Carolina

43 = South Dakota

44 = Tennessee

45 = Texas

46 = Utah

47 = Vermont

48 = Virgin Islands

49 = Virginia

50 = Washington

51 = West Virginia

52 = Wisconsin

53 = Wyoming

54 = Africa

55 = Asia

56 = Canada

57 = Central America and West Indies

58 = Europe

59 = Mexico

60 = Oceania

61 = Philippines

62 = South America

63 = U.S. Possessions

64 = American Samoa

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65 = Guam

97 = Northern Marianas

98 = Guam

99 = Unknown or if county code = 000 then this is

American Samoa

COMMENT: —

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 182

DMERC_LINE_SCRN_SVGS_AMT

LABEL: DMERC Line Screen Savings Amount

DESCRIPTION: The amount of savings attributable to the coverage screen for this DMERC line item.

SHORT NAME: SCRNSVGS

LONG NAME: DMERC_LINE_SCRN_SVGS_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: —

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 183

DMERC_LINE_SUPPLR_TYPE_CD

LABEL: DMERC Line Supplier Type Code

DESCRIPTION: The type of DMERC supplier.

SHORT NAME: SUP_TYPE

LONG NAME: DMERC_LINE_SUPPLR_TYPE_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: 0 = Clinics, groups, associations, partnerships, or other entities for whom the carrier's own ID number

has been assigned.

1 = Physicians or suppliers billing as solo practitioners for whom SSNs are shown in the physician ID

code field.

2 = Physicians or suppliers billing as solo practitioners for whom the carrier's own physician ID code is

shown.

3 = Suppliers (other than sole proprietorship) for whom employer identification (EI) numbers are used

in coding the ID field.

4 = Suppliers (other than sole proprietorship) for whom the carrier's own code has been shown.

5 = Institutional providers and independent laboratories for whom employer identification (EI)

numbers are used in coding the ID field.

6 = Institutional providers and independent laboratories for whom the carrier's own ID number is

shown.

7 = Clinics, groups, associations, or partnerships for whom employer identification (EI) numbers are

used in coding the ID field.

8 = Other entities for whom employer identification (EI) numbers are used in coding the ID field or

proprietorship for whom EI numbers are used in coding the ID field.

COMMENT: —

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DMERC_OXGN_EQUIP_INITL_DT

LABEL: Oxygen Equipment Initial Date

DESCRIPTION: The initial date for oxygen equipment.

SHORT NAME: DMERC_OXGN_EQUIP_INITL_DT

LONG NAME: DMERC_OXGN_EQUIP_INITL_DT

TYPE: DATE

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: This field is not populated before 2023. This is to support the elimination of the Certificate of Medical

Necessity (CMN).

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DMERC_OXGN_EQUIP_PRVS_DT

LABEL: Oxygen Equipment Previous Date

DESCRIPTION: The previous date for oxygen equipment. This date applies to claim lines that have a backdated initial

date indicator (DMERC_OXGN_INITL_DT_CD = B).

SHORT NAME: DMERC_OXGN_EQUIP_PRVS_DT

LONG NAME: DMERC_OXGN_EQUIP_PRVS_DT

TYPE: DATE

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: This field is not populated before 2023. This is to support the elimination of the Certificate of Medical

Necessity (CMN).

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DMERC_OXGN_INITL_DT_CD

LABEL: Oxygen Equipment Initial Date Code

DESCRIPTION: The initial date indicator for oxygen equipment.

SHORT NAME: DMERC_OXGN_INITL_DT_CD

LONG NAME: DMERC_OXGN_INITL_DT_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: I = Initial Date

B = Backdate Initial Date

R = Replacement Item

Null/missing = no oxygen equipment

COMMENT: This field is not populated before 2023. This is to support the elimination of the Certificate of Medical

Necessity (CMN).

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DOB_DT

LABEL: Date of Birth from Claim

DESCRIPTION: The beneficiary's date of birth.

SHORT NAME: DOB_DT

LONG NAME: DOB_DT

TYPE: DATE

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 188

DSH_OP_CLM_VAL_AMT

LABEL: Operating Disproportionate Share (DSH) Amount

DESCRIPTION: This is one component of the total amount that is payable on prospective payment system (PPS)

claims and reflects the DSH (disproportionate share hospital) payments for operating expenses (such

as labor) for the claim.

There are two types of DSH amounts that may be payable for many PPS claims; the other type of DSH

payment is for the DSH capital amount (variable called CLM_PPS_CPTL_DSPRPRTNT_SHR_AMT).

Both operating and capital DSH payments are components of the PPS, as well as numerous other

factors.

SHORT NAME: DSH_OP

LONG NAME: DSH_OP_CLM_VAL_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: Medicare payments are described in detail in a series of Medicare Payment Advisory Commission

(MedPAC) documents called “Payment Basics” (reference:https://www.medpac.gov/document-

type/payment-basic/).

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (reference:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/html/medicare-payment-systems.html).

DERIVATION RULES: If there is a value code “18” (i.e., in the value code file, if the VAL_CD=“18”) then

this dollar amount (VAL_AMT) is used to populate this field."

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EHR_PGM_RDCTN_IND_SW

LABEL: Claim Electronic Health Records (EHR) Program Reduction Indicator Switch

DESCRIPTION: This field is a switch that identifies which hospitals are Electronic Health Records (EHR) meaningful

users and distinguishes hospitals that will have a payment penalty for not being meaningful users.

SHORT NAME: EHR_PGM_RDCTN_IND_SW

LONG NAME: EHR_PGM_RDCTN_IND_SW

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: Y = hospital is subject to a reduction under the EHR program

Blank = not applicable

COMMENT: This field is new in October 2014. This field only applies to inpatient claims.

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EHR_PYMT_ADJSTMT_AMT

LABEL: Claim Electronic Health Record (EHR) Payment Adjustment Amount

DESCRIPTION: The claims adjustment payment amount for Hospitals that are not meaningful users of certified

Electronic Health Record (EHR) technology.

SHORT NAME: EHR_PYMT_ADJSTMT_AMT

LONG NAME: EHR_PYMT_ADJSTMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: This field was new in 2012 and is null/missing for all previous years.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 191

ESRD_TRTMT_CHS_IND_CD

LABEL: End-Stage Renal Disease (ESRD) Treatment Choices Demonstration Indicator Code

DESCRIPTION: The type of ESRD treatment Choices (ETC) Model (Demo code 94).

SHORT NAME: ESRD_TRTMT_CHS_IND_CD

LONG NAME: ESRD_TRTMT_CHS_IND_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: H or blank = Home Dialysis Payment Adjustment (HDPA) only

P = Performance Payment Adjustment (PPA) only

B = HDPA and PPA

COMMENT: The two types are, Home Dialysis Payment Adjustment (HDPA) and Performance Payment Adjustment

(PPA). This field is not populated prior to 2021.

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FI_CLM_ACTN_CD

LABEL: FI or MAC Claim Action Code

DESCRIPTION: The type of action requested by the intermediary to be taken on an institutional claim.

SHORT NAME: ACTIONCD

LONG NAME: FI_CLM_ACTN_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: 1 = Original debit action (always a 1 for all regular bills)

5 = Force action code 3 (secondary debit adjustment)

8 = Benefits refused

COMMENT: —

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FI_CLM_PROC_DT

LABEL: FI Claim Process Date

DESCRIPTION: The date the fiscal intermediary completes processing and releases the institutional claim to the CMS

common working file (CWF; stored in the NCH).

SHORT NAME: FI_CLM_PROC_DT

LONG NAME: FI_CLM_PROC_DT

TYPE: DATE

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 194

FI_NUM

LABEL: FI or MAC Number

DESCRIPTION: The identification number assigned by CMS to a fiscal intermediary (FI) authorized to process

institutional claim records.

Effective October 2006, the Medicare Administrative Contractors (MACs) began replacing the existing

fiscal intermediaries and started processing institutional claim records for states assigned to its

jurisdiction.

SHORT NAME: FI_NUM

LONG NAME: FI_NUM

TYPE: CHAR

LENGTH: 5

SOURCE: NCH

VALUES: Different FI/MAC carriers are under contract with CMS at different times.

Reference the CMS website for MAC Contract Status (for example):

https://www.cms.gov/medicare/medicare-contracting/medicare-administrative-contractors/who-are-

the-macs#MapsandLists

Fiscal Intermediary Numbers (as of October 2021):

00010 Alabama BC — Alabama (term. 05/2009)(replaced with MAC #10101)

00011 Alabama BC — Iowa (term. 10/2007) replaced by MAC # 03401)

00011 Cahaba — (RHHI) (term. 06/2011) replaced by MAC # 03401 )

00012 Iowa (terminated) replaced by MAC # 05101)

00012 Arizona — Noridian — J3 A MAC (AZA)(term. 05/2008)

00020 Arkansas BC — Arkansas

00021 Arkansas BC — Rhode Island(term. 05/2009)

00030 Arizona BC (term. 09/2007)(replaced by MAC # 03101)

00040 California BC (term. 11/2000)

00090 Florida BC (term. 02/2009)(replaced with MAC #09101)

00101 Georgia BC (term. 05/2009)(replaced with MAC #10201)

00130 Indiana BC/Administer Federal (term. 7/22/2012)(replaced with MAC # 08101)

00131 Illinois — Anthem

00140 Iowa — Wellmark (term. 05/2000)

00150 Kansas BC (term. 02/2008)(replaced with MAC # 05201)

00160 Kentucky — Anthem (term. 4/30/2011)(replaced with MAC # 15101)

00180 Maine BC (term. 05/2009)(replaced with MAC #14004 and 14101)

00180 Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island (Maine RHHI)(term.

05/2009)(replaced with MAC #14004 and 14101 )

00181 Massachusetts — Maine BC (term. 05/2009)

00190 Carefirst of Maryland (term. 09/2005)

00230 Mississippi BC

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00230 Trispan Health Services (LA-MS) (term. 09/2009)(previously also MOA)

00242 BCBS of MS (MOA) (term. 04/2008)(replaced with MAC # 05301)

00242 Missouri (terminated)(replaced with MAC # 05301)

00250 Montana BC (term. 11/2006)(replaced by MAC # 03201)

00260 Nebraska BC (term. 11/2007)(replaced with MAC # 05401)

00270 New Hampshire BC — New Hampshire, Vermont (term. 06/2009)(replaced with MAC #14501)

00280 New Jersey BC (term. 07/2000)

00308 Empire BC — New York, Connecticut, and Delaware (term. 11/2008)(replaced with MAC #

12101, 13201 and 13101)

00310 North Carolina BC (term. 09/2002)

00320 North Dakota BC — North Dakota (term. 12/1/2006)(replaced with MAC # 03301)

00322 North Dakota BC — Washington and Alaska

00323 North Dakota BC — Idaho, Oregon, and Utah (term. 11/2006)(replaced with MAC # 03501)

00325 Noridian — Idaho, Oregon

00332 Administar — Ohio Anthem — Ohio

00340 Oklahoma BC (term. 02/2008)(replaced with MAC # 04301)

00350 Regence — Oregon, Idaho, Utah (term. 11/2005)

00363 Pennsylvania/Highmark — Veritus (term. 07/2008)

00366 Highmark (MD and DC) — Part A (eff. 10/2005)(term. 07/2008)

00370 Rhode Island BC (term. 03/2004)(replaced with MAC #14401)

00380 South Carolina BC — South Carolina (term. 01/2011)(replaced with MAC #11004 and 11201)

00380 Palmetto GBA — AL, AR, GA, FL, IL, IN, KY, LA, MS, MN, NC, OK, OH, SC, TN, TX (term. 01/2011)

00382 South Carolina BC — North Carolina (term. 10/2010)(replaced with MAC #11501)

00390 Riverbend BC — New Jersey, Tennessee (term. 08/2009)(replaced with MAC # 12001 and

10301)

00400 Texas BC — Colorado, New Mexico, Texas (term. 05/2008)(replaced with MAC #04101, 04201,

04401 — refer below)

00410 Utah BC (term. 09/2000)

00430 Premera BC — Washington, Alaska(term. 09/2004)

00450 Wisconsin BC — Wisconsin

00450 Michigan, Minnesota, New Jersey, New York, Wisconsin (RHHI)

00452 Wisconsin BC — Michigan (term. 7/22/2012)(replaced with MAC # 08201)

00453 Wisconsin BC — Virginia and West Virginia(term. 05/2011)(replaced with MAC #11301 and

11401)

00454 Wisconsin BC — California, Hawaii, Nevada (RHHI)(term. 08/2008)(replaced by MAC #01101,

01201 and 01301 — refer below)

00460 Wyoming BC (term. 10/2006)(replaced by MAC # 03601)

00468 North Carolina BC/CPRTIVA (terminated)

01101 California (eff. 8/15/2008)(replaces FI #00454)

01111 California entire state — Noridian Healthcare Solutions

01201 Hawaii (eff. 8/15/2008)(replaces FI #00454)

01211 Guam, Hawaii, Northern Mariana Islands — Noridian Healthcare Solutions

01301 Nevada (eff. 8/15/2008)(replaces FI #00454)

01311 Nevada — Noridian Healthcare Solutions

01390 AETNA — Washington

01911 American Samoa, California — entire state, Guam, Hawaii, Nevada, Northern Mariana Islands

— Noridian Healthcare Solutions

02101 Alaska (eff. 02/01/2012)

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02201 Idaho (eff. 02/01/2012)

02301 Oregon (eff. 02/01/2012)

02401 Washington (eff. 02/01/2012)

03001 JF Roll-up (2/3)(Orig. J3 term. 09/2007)

03101 Arizona (eff. 10/1/2007)(replaces FI #00030)

03201 Montana (eff. 12/1/2006)(replaces FI #00250)

03301 North Dakota (eff. 12/1/2006)(replaces FI #00320)

03401 South Dakota (eff. 3/1/2007)(replaces FI #00011)

03501 Utah (eff. 12/1/2006)(replaces FI #00323)

03601 Wyoming (eff. 11/1/2006)(replaces FI #00460)

04101 Colorado (eff. 6/1/2008) (terminated)(replaces FI #00400)

04111 Colorado (eff. 10/29/2012)

04201 New Mexico (eff. 6/16/2008)(replaces FI #00400)

04211 New Mexico (eff. 10/29/2012)

04301 Oklahoma (eff. 3/1/2008)(replaces FI #00340)

04311 Oklahoma (eff. 10/29/2012)

04401 Texas (eff. 6/16/2008)(replaces FI #00400)

04411 Texas (eff. 10/29/2012)

04911 WPS (Mutual of Omaha Legacy)(eff. 10/29/2012)

05101 Iowa (eff. 5/1/2008)(replaces FI #00012)

05201 Kansas (eff. 03/01/2008)(replaces FI #00150)

05301 West Missouri (eff. 5/1/2008)(replaces FI #00242)

05401 Physicians Service Insurance Corporation — Wisconsin

05901 Missouri-Entire state — Wisconsin Physicians Service Insurance Corporation

06001 J6 Roll-up

06014 RHHI Region D AK, AZ, CA, HI, ID, NV, OR, WA, American Samoa, Guam, and the Northern

Marianas

06101 Illinois

06201 Minnesota

07101 Arkansas (eff. 08/20/2012)

07201 Louisiana (eff. 08/20/2012)

07301 Mississippi (eff. 08/20/2012)

08101 Indiana, WPS J8 (eff. 07/23/2012)

08201 Michigan, WPS J8(eff. 07/23/2012)

09101 Florida (eff. 2/13/2009)

09201 Puerto Rico (eff. 03/02/2009)

10111 Alabama — Palmetto GBA

10211 Georgia — Palmetto GBA

10311 Tennessee — Palmetto GBA

11004 Region C (HHH C RHHI) (eff. 1/24/2011)

11201 South Carolina (eff. 1/24/2011)

11301 Virginia (eff. 5/16/2011)

11401 West Virginia (eff. 5/16/2011)

11501 North Carolina (eff. 10/01/2010)

12101 Delaware (eff. 11/14/2008)(replaces FI # 00308)

12201 District of Columbia (eff. 08/01/2008)

12301 Maryland (eff. 08/01/2008)

12401 New Jersey (eff. 9/1/2008)(replaces FI # 00390)

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12501 Pennsylvania (eff. 08/01/2008)

12901 Novitas Solutions J12

13101 Connecticut (eff. 8/1/2008)(replaces FI #00308)

13201 NGS-New York (eff. 7/18/2008)(replaces FI #00308)

14014 Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont – National

Government Services, Inc

14111 Maine — National Government Services, Inc

14211 Massachusetts — National Government Services, Inc.

14311 New Hampshire — National Government Services, Inc.

14411 Rhode Island — National Government Services, Inc.

14511 Vermont — National Government Services, Inc

15004 CGS Government Services (HHH B RHHI)(eff. 06/13/2011)

15101 Kentucky (eff. 10/17/2011)

15201 Ohio (eff. 10/17/2011)

50333 Travelers; Connecticut United Healthcare(term. 07/2000)

52280 NE — Mutual of Omaha

52280 Mutual of Omaha (NT) Note: Nebraska — 00260 (NE) and 52280 (NT)

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 198

FINL_STD_AMT

LABEL: Claim Final Standard Payment Amount

DESCRIPTION: This amount further adjusts the standard Medicare Payment amount (field called

PPS_STD_VAL_PYMT_AMT) by applying additional standardization requirements (e.g., sequestration).

SHORT NAME: FINL_STD_AMT

LONG NAME: FINL_STD_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XX.XX

COMMENT: This amount is never used for payments. It is used for comparisons across different regions of the

country for the value-based purchasing initiatives and for research. It is a standard Medicare payment

amount, without the geographical payment adjustments and some of the other add-on payments that

actually go to the hospitals.

This field first appeared in inpatient claims in October 2014. For HHA claims, this field first appeared in

July 2018 and is called PPS_STD_VAL_PYMT_AMT.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 199

FST_DGNS_E_CD

LABEL: First Claim Diagnosis E Code

DESCRIPTION: The code used to identify the 1st external cause of injury, poisoning, or other adverse effect. This

diagnosis E code is also stored as the 1st occurrence of the diagnosis E code trailer.

SHORT NAME: FST_DGNS_E_CD

LONG NAME: FST_DGNS_E_CD

TYPE: CHAR

LENGTH: 7

SOURCE: NCH

VALUES: —

COMMENT: Prior to version “J,” this field was named: CLM_DGNS_E_CD.

Effective with version “J,” this field has been expanded from 5 bytes to 7 bytes to accommodate ICD-

10.

On October 1, 2015, the conversion from the 9th version of the International Classification of Diseases

(ICD-9-CM) to version 10 (ICD-10-CM) occurred.

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FST_DGNS_E_VRSN_CD

LABEL: First Claim Diagnosis E Code Diagnosis Version Code (ICD-9 or ICD-10)

DESCRIPTION: Effective with version “J,” the code used to indicate if the diagnosis E code is ICD-9 or ICD-10.

SHORT NAME: FST_DGNS_E_VRSN_CD

LONG NAME: FST_DGNS_E_VRSN_CD

TYPE: CHAR

LENGTH: 1

SOURCE: —

VALUES: Blank = ICD-9

9 = ICD-9

0 = ICD-10

COMMENT: With 5010, the diagnosis and procedure codes were expanded to accommodate the future

implementation of ICD-10.

On October 1, 2015, the conversion from the 9th version of the International Classification of Diseases

(ICD-9-CM) to version 10 (ICD-10-CM) occurred.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 201

GNDR_CD

LABEL: Gender Code from Claim

DESCRIPTION: The sex of a beneficiary.

SHORT NAME: GNDR_CD

LONG NAME: GNDR_CD

TYPE: CHAR

LENGTH: 1

SOURCE: SSA, RRB, EDB

VALUES: 0 = Unknown

1 = Male

2 = Female

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 202

HAC_PGM_RDCTN_IND_SW

LABEL: Claim Hospital Acquired Condition (HAC) Program Reduction Indicator Switch

DESCRIPTION: This field is a switch that identifies hospitals subject to a Hospital Acquired Conditions (HAC) reduction

of what they would otherwise be paid under the inpatient prospective payment system (IPPS).

SHORT NAME: HAC_PGM_RDCTN_IND_SW

LONG NAME: HAC_PGM_RDCTN_IND_SW

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: Y = hospital subject to a reduction under the HAC Reduction Program

N = hospital is not subject to a reduction under the HAC Reduction Program

COMMENT: This field is new in October 2014. This field only applies to inpatient claims.

For details on the CMS hospital readmission reduction program reference the CMS website:

http://www.cms.gov/Medicare/Medicare-Fee-For-Service-Payment/AcuteInpatientPPS/Readmissions-

Reduction-Program.html

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HCPCS_1ST_MDFR_CD

LABEL: HCPCS Initial Modifier Code

DESCRIPTION: A first modifier to the Healthcare Common Procedure Coding System (HCPCS) procedure code to

enable a more specific procedure identification for the revenue center or line-item service for the

claim.

SHORT NAME: MDFR_CD1

LONG NAME: HCPCS_1ST_MDFR_CD

TYPE: CHAR

LENGTH: 5

SOURCE: NCH

VALUES: —

COMMENT: —

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HCPCS_2ND_MDFR_CD

LABEL: HCPCS Second Modifier Code

DESCRIPTION: A second modifier to the Healthcare Common Procedure Coding System (HCPCS) procedure code to

make it more specific than the first modifier code to identify the revenue center or line-item service

for the claim.

SHORT NAME: MDFR_CD2

LONG NAME: HCPCS_2ND_MDFR_CD

TYPE: CHAR

LENGTH: 5

SOURCE: NCH

VALUES: —

COMMENT: —

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HCPCS_3RD_MDFR_CD

LABEL: HCPCS Third Modifier Code

DESCRIPTION: A third modifier to the Healthcare Common Procedure Coding System (HCPCS) procedure code to

make it more specific than the first or second modifier codes to identify the revenue center or line-

item services for the claim.

SHORT NAME: MDFR_CD3

LONG NAME: HCPCS_3RD_MDFR_CD

TYPE: CHAR

LENGTH: 5

SOURCE: NCH

VALUES: —

COMMENT: —

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HCPCS_4TH_MDFR_CD

LABEL: HCPCS Fourth Modifier Code

DESCRIPTION: A fourth modifier to the Healthcare Common Procedure Coding System (HCPCS) procedure code to

make it more specific than the first, second, or third modifier codes identify the revenue center or

line-item services for the claim.

SHORT NAME: MDFR_CD4

LONG NAME: HCPCS_4TH_MDFR_CD

TYPE: CHAR

LENGTH: 5

SOURCE: NCH

VALUES: —

COMMENT: This field is available only in the Hospital outpatient data file (no other claim types).

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HCPCS_CD

LABEL: Healthcare Common Procedure Coding System (HCPCS) Code

DESCRIPTION: The Healthcare Common Procedure Coding System (HCPCS) is a collection of codes that represent

procedures, supplies, products, and services which may be provided to Medicare beneficiaries and to

individuals enrolled in private health insurance programs. The codes are divided into three levels, or

groups, as described below (in COMMENT).

In the Institutional Claim Revenue Center Files, this variable can indicate the specific case-mix

grouping that Medicare used to pay for skilled nursing facility (SNF), home health, or inpatient

rehabilitation facility (IRF) services (reference NOTE 2 in COMMENT section below).

SHORT NAME: HCPCS_CD

LONG NAME: HCPCS_CD

TYPE: CHAR

LENGTH: 5

SOURCE: NCH

VALUES: —

COMMENT: Level I

Codes and descriptors copyrighted by the American Medical Association's Current Procedural

Terminology, Fourth Edition (CPT-4). These are 5-position numeric codes representing physician and

non-physician services.

NOTE 1: CPT-4 codes including both long and short descriptions shall be used in accordance with the

CMS/AMA agreement. Any other use violates the AMA copyright.

Level II

Includes codes and descriptors copyrighted by the American Dental Association's Current Dental

Terminology, Fifth Edition (CDT-5). These are five-position alpha-numeric codes comprising the D

series. All other level II codes and descriptors are approved and maintained jointly by the alpha-

numeric editorial panel (consisting of CMS, the Health Insurance Association of America, and the Blue

Cross and Blue Shield Association). These are 5-position alpha-numeric codes representing primarily

items and non-physician services that are not represented in the level I codes.

Level III

Codes and descriptors developed by Medicare carriers (currently known as Medicare Administrative

Contractors; MACs) for use at the local (MAC) level. These are five-position alpha-numeric codes in the

W, X, Y or Z series representing physician and non-physician services that are not represented in the

level I or level II codes.

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NOTE 2: This field may contain information regarding case-mix grouping that Medicare used to pay for

SNF, home health, or IRF services. These groupings are sometimes known as Health Insurance

prospective payment system (HIPPS) codes.

This field will contain a HIPPS code if the revenue center code (REV_CNTR) equals 0022 for SNF care,

0023 for home health, or 0024 for IRF care.

For home health claims, please also reference the revenue center APC/HIPPS code variable

(REV_CNTR_APC_HIPPS_CD).

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HPSA_SCRCTY_IND_CD

LABEL: Carrier Line Health Professional Shortage Area (HPSA)/Scarcity Indicator Code

DESCRIPTION: The code used to track health professional shortage area (HPSA) and physician scarcity bonus

payments on carrier claims.

SHORT NAME: HPSASCCD

LONG NAME: HPSA_SCRCTY_IND_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: 1 = HPSA

2 = Scarcity

3 = Both

5 =HPSA and HSIP

6 =PCIP

7 = HPSA and PCIP

Space = Not applicable

COMMENT: This variable was added 10/3/2005 with the implementation of NCH/NMUD CR#2.

Prior to 10/3/2005, claims contained a modifier code to indicate the bonus payment. A “QU”

represented a HPSA bonus payment and an “AR” represented a scarcity bonus payment. As of

1/1/2005, the modifiers were no longer being reported by the provider. NCH and NMUD were not

ready to accept the new field until 10/3/2005.

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ICD_DGNS_CD1

ICD_DGNS_CD2

ICD_DGNS_CD3

ICD_DGNS_CD4

ICD_DGNS_CD5

ICD_DGNS_CD6

ICD_DGNS_CD7

ICD_DGNS_CD8

ICD_DGNS_CD9

ICD_DGNS_CD10

ICD_DGNS_CD11

ICD_DGNS_CD12

ICD_DGNS_CD13

ICD_DGNS_CD14

ICD_DGNS_CD15

ICD_DGNS_CD16

ICD_DGNS_CD17

ICD_DGNS_CD18

ICD_DGNS_CD19

ICD_DGNS_CD20

ICD_DGNS_CD21

ICD_DGNS_CD22

ICD_DGNS_CD23

ICD_DGNS_CD24

ICD_DGNS_CD25

LABEL: Claim Diagnosis Code

DESCRIPTION: The diagnosis code identifying the beneficiary's diagnosis.

SHORT NAME:

ICD_DGNS_CD1

ICD_DGNS_CD2

ICD_DGNS_CD3

ICD_DGNS_CD4

ICD_DGNS_CD5

ICD_DGNS_CD6

ICD_DGNS_CD7

ICD_DGNS_CD8

ICD_DGNS_CD9

ICD_DGNS_CD10

ICD_DGNS_CD11

ICD_DGNS_CD12

ICD_DGNS_CD13

ICD_DGNS_CD14

ICD_DGNS_CD15

ICD_DGNS_CD16

ICD_DGNS_CD17

ICD_DGNS_CD18

ICD_DGNS_CD19

ICD_DGNS_CD20

ICD_DGNS_CD21

ICD_DGNS_CD22

ICD_DGNS_CD23

ICD_DGNS_CD24

ICD_DGNS_CD25

LONG NAME:

ICD_DGNS_CD1

ICD_DGNS_CD2

ICD_DGNS_CD3

ICD_DGNS_CD4

ICD_DGNS_CD5

ICD_DGNS_CD6

ICD_DGNS_CD7

ICD_DGNS_CD8

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ICD_DGNS_CD9

ICD_DGNS_CD10

ICD_DGNS_CD11

ICD_DGNS_CD12

ICD_DGNS_CD13

ICD_DGNS_CD14

ICD_DGNS_CD15

ICD_DGNS_CD16

ICD_DGNS_CD17

ICD_DGNS_CD18

ICD_DGNS_CD19

ICD_DGNS_CD20

ICD_DGNS_CD21

ICD_DGNS_CD22

ICD_DGNS_CD23

ICD_DGNS_CD24

ICD_DGNS_CD25

TYPE: CHAR

LENGTH: 7

SOURCE: NCH

VALUES: —

COMMENT: For ICD-9 diagnosis codes, this is a 3–5 digit numeric or alpha/numeric value; it can include leading

zeros. On October 1, 2015, the conversion from the 9th version of the International Classification of

Diseases (ICD-9-CM) to version 10 (ICD-10-CM) occurred.

Starting in 2011, with version J of the NCH claim layout, institutional claims can have up to 25

diagnosis codes (previously only 11 were accommodated), and the non-institutional claims can have

up to 12 diagnosis codes (previously only up to 8).

The lower the number, the more important the diagnosis in the patient treatment/billing (i.e.,

ICD_DGNS_CD1 is considered the primary diagnosis).

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ICD_DGNS_E_CD1

ICD_DGNS_E_CD2

ICD_DGNS_E_CD3

ICD_DGNS_E_CD4

ICD_DGNS_E_CD5

ICD_DGNS_E_CD6

ICD_DGNS_E_CD7

ICD_DGNS_E_CD8

ICD_DGNS_E_CD9

ICD_DGNS_E_CD10

ICD_DGNS_E_CD11

ICD_DGNS_E_CD12

LABEL: Claim Diagnosis E Code

DESCRIPTION: The code used to identify the external cause of injury, poisoning, or other adverse effect.

SHORT NAME:

ICD_DGNS_E_CD1

ICD_DGNS_E_CD2

ICD_DGNS_E_CD3

ICD_DGNS_E_CD4

ICD_DGNS_E_CD5

ICD_DGNS_E_CD6

ICD_DGNS_E_CD7

ICD_DGNS_E_CD8

ICD_DGNS_E_CD9

ICD_DGNS_E_CD10

ICD_DGNS_E_CD11

ICD_DGNS_E_CD12

LONG NAME:

ICD_DGNS_E_CD1

ICD_DGNS_E_CD2

ICD_DGNS_E_CD3

ICD_DGNS_E_CD4

ICD_DGNS_E_CD5

ICD_DGNS_E_CD6

ICD_DGNS_E_CD7

ICD_DGNS_E_CD8

ICD_DGNS_E_CD9

ICD_DGNS_E_CD10

ICD_DGNS_E_CD11

ICD_DGNS_E_CD12

TYPE: CHAR

LENGTH: 7

SOURCE: NCH

VALUES: —

COMMENT: Effective with version “J,” this field has been expanded from 5 bytes to 7 bytes to accommodate ICD-

10.

On October 1, 2015, the conversion from the 9th version of the International Classification of Diseases

(ICD-9-CM) to version 10 (ICD-10-CM) occurred.

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ICD_DGNS_VRSN_CD1

ICD_DGNS_VRSN_CD2

ICD_DGNS_VRSN_CD3

ICD_DGNS_VRSN_CD4

ICD_DGNS_VRSN_CD5

ICD_DGNS_VRSN_CD6

ICD_DGNS_VRSN_CD7

ICD_DGNS_VRSN_CD8

ICD_DGNS_VRSN_CD9

ICD_DGNS_VRSN_CD10

ICD_DGNS_VRSN_CD11

ICD_DGNS_VRSN_CD12

ICD_DGNS_VRSN_CD13

ICD_DGNS_VRSN_CD14

ICD_DGNS_VRSN_CD15

ICD_DGNS_VRSN_CD16

ICD_DGNS_VRSN_CD17

ICD_DGNS_VRSN_CD18

ICD_DGNS_VRSN_CD19

ICD_DGNS_VRSN_CD20

ICD_DGNS_VRSN_CD21

ICD_DGNS_VRSN_CD22

ICD_DGNS_VRSN_CD23

ICD_DGNS_VRSN_CD24

ICD_DGNS_VRSN_CD25

LABEL: Claim Diagnosis Code Version Code (ICD-9 or ICD-10)

DESCRIPTION: Effective with version “J,” the code used to indicate if the diagnosis code is ICD-9/ICD-10.

SHORT NAME:

ICD_DGNS_VRSN_CD1

ICD_DGNS_VRSN_CD2

ICD_DGNS_VRSN_CD3

ICD_DGNS_VRSN_CD4

ICD_DGNS_VRSN_CD5

ICD_DGNS_VRSN_CD6

ICD_DGNS_VRSN_CD7

ICD_DGNS_VRSN_CD8

ICD_DGNS_VRSN_CD9

ICD_DGNS_VRSN_CD10

ICD_DGNS_VRSN_CD11

ICD_DGNS_VRSN_CD12

ICD_DGNS_VRSN_CD13

ICD_DGNS_VRSN_CD14

ICD_DGNS_VRSN_CD15

ICD_DGNS_VRSN_CD16

ICD_DGNS_VRSN_CD17

ICD_DGNS_VRSN_CD18

ICD_DGNS_VRSN_CD19

ICD_DGNS_VRSN_CD20

ICD_DGNS_VRSN_CD21

ICD_DGNS_VRSN_CD22

ICD_DGNS_VRSN_CD23

ICD_DGNS_VRSN_CD24

ICD_DGNS_VRSN_CD25

LONG NAME:

ICD_DGNS_VRSN_CD1

ICD_DGNS_VRSN_CD2

ICD_DGNS_VRSN_CD3

ICD_DGNS_VRSN_CD4

ICD_DGNS_VRSN_CD5

ICD_DGNS_VRSN_CD6

ICD_DGNS_VRSN_CD7

ICD_DGNS_VRSN_CD8

ICD_DGNS_VRSN_CD9

ICD_DGNS_VRSN_CD10

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ICD_DGNS_VRSN_CD11

ICD_DGNS_VRSN_CD12

ICD_DGNS_VRSN_CD13

ICD_DGNS_VRSN_CD14

ICD_DGNS_VRSN_CD15

ICD_DGNS_VRSN_CD16

ICD_DGNS_VRSN_CD17

ICD_DGNS_VRSN_CD18

ICD_DGNS_VRSN_CD19

ICD_DGNS_VRSN_CD20

ICD_DGNS_VRSN_CD21

ICD_DGNS_VRSN_CD22

ICD_DGNS_VRSN_CD23

ICD_DGNS_VRSN_CD24

ICD_DGNS_VRSN_CD25

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: Blank = ICD-9

9 = ICD-9

0 = ICD-10

COMMENT: On October 1, 2015, the conversion from the 9th version of the International Classification of Diseases

(ICD-9-CM) to version 10 (ICD-10-CM) occurred.

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ICD_PRCDR_CD1

ICD_PRCDR_CD2

ICD_PRCDR_CD3

ICD_PRCDR_CD4

ICD_PRCDR_CD5

ICD_PRCDR_CD6

ICD_PRCDR_CD7

ICD_PRCDR_CD8

ICD_PRCDR_CD9

ICD_PRCDR_CD10

ICD_PRCDR_CD11

ICD_PRCDR_CD12

ICD_PRCDR_CD13

ICD_PRCDR_CD14

ICD_PRCDR_CD15

ICD_PRCDR_CD16

ICD_PRCDR_CD17

ICD_PRCDR_CD18

ICD_PRCDR_CD19

ICD_PRCDR_CD20

ICD_PRCDR_CD21

ICD_PRCDR_CD22

ICD_PRCDR_CD23

ICD_PRCDR_CD24

ICD_PRCDR_CD25

LABEL: Claim Procedure Code

DESCRIPTION: The code that indicates the procedure performed during the period covered by the institutional claim.

SHORT NAME:

ICD_PRCDR_CD1

ICD_PRCDR_CD2

ICD_PRCDR_CD3

ICD_PRCDR_CD4

ICD_PRCDR_CD5

ICD_PRCDR_CD6

ICD_PRCDR_CD7

ICD_PRCDR_CD8

ICD_PRCDR_CD9

ICD_PRCDR_CD10

ICD_PRCDR_CD11

ICD_PRCDR_CD12

ICD_PRCDR_CD13

ICD_PRCDR_CD14

ICD_PRCDR_CD15

ICD_PRCDR_CD16

ICD_PRCDR_CD17

ICD_PRCDR_CD18

ICD_PRCDR_CD19

ICD_PRCDR_CD20

ICD_PRCDR_CD21

ICD_PRCDR_CD22

ICD_PRCDR_CD23

ICD_PRCDR_CD24

ICD_PRCDR_CD25

LONG NAME:

ICD_PRCDR_CD1

ICD_PRCDR_CD2

ICD_PRCDR_CD3

ICD_PRCDR_CD4

ICD_PRCDR_CD5

ICD_PRCDR_CD6

ICD_PRCDR_CD7

ICD_PRCDR_CD8

ICD_PRCDR_CD9

ICD_PRCDR_CD10

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ICD_PRCDR_CD11

ICD_PRCDR_CD12

ICD_PRCDR_CD13

ICD_PRCDR_CD14

ICD_PRCDR_CD15

ICD_PRCDR_CD16

ICD_PRCDR_CD17

ICD_PRCDR_CD18

ICD_PRCDR_CD19

ICD_PRCDR_CD20

ICD_PRCDR_CD21

ICD_PRCDR_CD22

ICD_PRCDR_CD23

ICD_PRCDR_CD24

ICD_PRCDR_CD25

TYPE: CHAR

LENGTH: 7

SOURCE: NCH

VALUES: —

COMMENT: Effective July 2004, ICD-9-CM procedure codes are no longer being accepted on outpatient claims.

The ICD-9-CM codes were named as the HIPPA standard code set for inpatient hospital procedures.

HCPCS/CPT codes were named as the standard code set for physician services and other health care

services.

ICD_PRCDR_CD1 is considered the primary procedure performed.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 217

ICD_PRCDR_VRSN_CD1

ICD_PRCDR_VRSN_CD2

ICD_PRCDR_VRSN_CD3

ICD_PRCDR_VRSN_CD4

ICD_PRCDR_VRSN_CD5

ICD_PRCDR_VRSN_CD6

ICD_PRCDR_VRSN_CD7

ICD_PRCDR_VRSN_CD8

ICD_PRCDR_VRSN_CD9

ICD_PRCDR_VRSN_CD10

ICD_PRCDR_VRSN_CD11

ICD_PRCDR_VRSN_CD12

ICD_PRCDR_VRSN_CD13

ICD_PRCDR_VRSN_CD14

ICD_PRCDR_VRSN_CD15

ICD_PRCDR_VRSN_CD16

ICD_PRCDR_VRSN_CD17

ICD_PRCDR_VRSN_CD18

ICD_PRCDR_VRSN_CD19

ICD_PRCDR_VRSN_CD20

ICD_PRCDR_VRSN_CD21

ICD_PRCDR_VRSN_CD22

ICD_PRCDR_VRSN_CD23

ICD_PRCDR_VRSN_CD24

ICD_PRCDR_VRSN_CD25

LABEL: Claim Procedure Code Version Code (ICD-9 or ICD-10)

DESCRIPTION: The code used to indicate if the procedure code is ICD-9 or ICD-10.

SHORT NAME:

ICD_PRCDR_VRSN_CD1

ICD_PRCDR_VRSN_CD2

ICD_PRCDR_VRSN_CD3

ICD_PRCDR_VRSN_CD4

ICD_PRCDR_VRSN_CD5

ICD_PRCDR_VRSN_CD6

ICD_PRCDR_VRSN_CD7

ICD_PRCDR_VRSN_CD8

ICD_PRCDR_VRSN_CD9

ICD_PRCDR_VRSN_CD10

ICD_PRCDR_VRSN_CD11

ICD_PRCDR_VRSN_CD12

ICD_PRCDR_VRSN_CD13

ICD_PRCDR_VRSN_CD14

ICD_PRCDR_VRSN_CD15

ICD_PRCDR_VRSN_CD16

ICD_PRCDR_VRSN_CD17

ICD_PRCDR_VRSN_CD18

ICD_PRCDR_VRSN_CD19

ICD_PRCDR_VRSN_CD20

ICD_PRCDR_VRSN_CD21

ICD_PRCDR_VRSN_CD22

ICD_PRCDR_VRSN_CD23

ICD_PRCDR_VRSN_CD24

ICD_PRCDR_VRSN_CD25

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LONG NAME:

ICD_PRCDR_VRSN_CD1

ICD_PRCDR_VRSN_CD2

ICD_PRCDR_VRSN_CD3

ICD_PRCDR_VRSN_CD4

ICD_PRCDR_VRSN_CD5

ICD_PRCDR_VRSN_CD6

ICD_PRCDR_VRSN_CD7

ICD_PRCDR_VRSN_CD8

ICD_PRCDR_VRSN_CD9

ICD_PRCDR_VRSN_CD10

ICD_PRCDR_VRSN_CD11

ICD_PRCDR_VRSN_CD12

ICD_PRCDR_VRSN_CD13

ICD_PRCDR_VRSN_CD14

ICD_PRCDR_VRSN_CD15

ICD_PRCDR_VRSN_CD16

ICD_PRCDR_VRSN_CD17

ICD_PRCDR_VRSN_CD18

ICD_PRCDR_VRSN_CD19

ICD_PRCDR_VRSN_CD20

ICD_PRCDR_VRSN_CD21

ICD_PRCDR_VRSN_CD22

ICD_PRCDR_VRSN_CD23

ICD_PRCDR_VRSN_CD24

ICD_PRCDR_VRSN_CD25

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: Blank = ICD-9

9 = ICD-9

0 = ICD-10

COMMENT: On October 1, 2015, the conversion from the 9th version of the International Classification of Diseases

(ICD-9-CM) to version 10 (ICD-10-PCS) occurred.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 219

IME_OP_CLM_VAL_AMT

LABEL: Operating Indirect Medical Education (IME) Amount

DESCRIPTION: This is one component of the total amount that is payable on PPS claims, and reflects the IME (indirect

medical education) payments for operating expenses (such as labor) for the claim.

There are two types of IME amounts that may be payable for many PPS claims; the other type of IME

payment is for the IME capital amount (variable called CLM_PPS_CPTL_IME_AMT). Both operating and

capital IME payments are components of the PPS, as well as numerous other factors.

SHORT NAME: IME_OP

LONG NAME: IME_OP_CLM_VAL_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: Medicare payments are described in detail in a series of Medicare Payment Advisory Commission

(MedPAC) documents called “Payment Basics” (reference: https://www.medpac.gov/document-

type/payment-basic/)

Also, in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (reference:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/html/medicare-payment-systems.html)

Derivation Rules: If there is a value code “19” (i.e., in the value code file, if the VAL_CD=“19”) then this

dollar amount (VAL_AMT) is used to populate this field.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 220

LINE_1ST_EXPNS_DT

LABEL: Line First Expense Date

DESCRIPTION: Beginning date (1st expense) for this line-item service on the non-institutional claim.

SHORT NAME: EXPNSDT1

LONG NAME: LINE_1ST_EXPNS_DT

TYPE: DATE

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: —

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 221

LINE_ADJUST_GRP_CD

LABEL: Line Adjustment Group Code

DESCRIPTION: Claim adjustment group code used to categorize a payment adjustment for a claim or claim line. This

field is currently only populated for Direct Contracting (DC), Comprehensive Kidney Care Contracting

(CKCC) and Kidney Care First (KCF) model claims.

SHORT NAME: LINE_ADJUST_GRP_CD

LONG NAME: LINE_ADJUST_GRP_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES: CO = Contractual obligation

OA = Other adjustment

PR = Patient responsibility

COMMENT: This code set is an external code set maintained by X12 (www.x12.org/codes). This field is not

populated prior to 2021.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 222

LINE_ADJUST_RSN_CD

LABEL: Line Adjustment Reason Code

DESCRIPTION: Claim adjustment reason code used to describe why a claim or claim line was paid differently than

billed. This field is currently only populated for Direct Contracting (DC), Comprehensive Kidney Care

Contracting (CKCC) and Kidney Care First (KCF) model claims.

SHORT NAME: LINE_ADJUST_RSN_CD

LONG NAME: LINE_ADJUST_RSN_CD

TYPE: CHAR

LENGTH: 5

SOURCE: NCH

VALUES: This is not a comprehensive list of values; refer to website below for current values and descriptions:

132 = Prearranged demonstration project adjustment

COMMENT: This code set is an external code set maintained by X12 (www.x12.org/codes). This field is not

populated prior to 2021.

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 223

LINE_ALOWD_CHRG_AMT

LABEL: Line Allowed Charge Amount

DESCRIPTION: The amount of allowed charges for the line-item service on the non-institutional claim.

This charge is used to compute the total claim-level payment to providers or reimbursement to

beneficiaries.

SHORT NAME: LALOWCHG

LONG NAME: LINE_ALOWD_CHRG_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: The amount includes both the line-item Medicare and beneficiary-paid amounts (i.e., deductible and

coinsurance).

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 224

LINE_BENE_PMT_AMT

LABEL: Line Payment Amount to Beneficiary

DESCRIPTION: The payment (reimbursement) made to the beneficiary related to the line-item service on the non-

institutional claim.

SHORT NAME: LBENPMT

LONG NAME: LINE_BENE_PMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: —

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 225

LINE_BENE_PRMRY_PYR_CD

LABEL: Line Primary Payer Code (if not Medicare)

DESCRIPTION: The code specifying a federal non-Medicare program or other source that has primary responsibility

for the payment of the Medicare beneficiary's medical bills relating to the line-item service on the

non-institutional claim.

The presence of a primary payer code indicates that some other payer besides Medicare covered at

least some portion of the charges.

SHORT NAME: LPRPAYCD

LONG NAME: LINE_BENE_PRMRY_PYR_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH, VA, DOL, SSA

VALUES: A = Working aged bene/spouse with employer group health plan (EGHP)

B = End-stage renal disease (ESRD) beneficiary in the 18-month coordination period with an employer

group health plan

C = Conditional payment by Medicare; future reimbursement expected

D = Automobile no-fault

E = Workers' compensation

F = Public Health Service or other federal agency (other than Dept. of Veterans Affairs)

G = Working disabled bene (under age 65 with LGHP)

H = Black Lung

I = Dept. of Veterans Affairs

L = Any liability insurance

M = Override code: EGHP services involved

N = Override code: non-EGHP services involved

W = Workers’ Compensation Medicare Set-Aside Arrangement (WCMSA)

Null/missing= Medicare is primary payer

COMMENT: Values C, M, N, and null/missing indicate Medicare is primary payer.

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LINE_BENE_PRMRY_PYR_PD_AMT

LABEL: Line Primary Payer (if not Medicare) Paid Amount

DESCRIPTION: The amount of a payment made on behalf of a Medicare beneficiary by a primary payer other than

Medicare, that the provider is applying to covered Medicare charges for the line-item service on the

non-institutional claim.

SHORT NAME: LPRPDAMT

LONG NAME: LINE_BENE_PRMRY_PYR_PD_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 227

LINE_BENE_PTB_DDCTBL_AMT

LABEL: Line Beneficiary Part B Deductible Amount

DESCRIPTION: The amount of money for which the carrier has determined that the beneficiary is liable for the Part B

cash deductible for the line-item service on the non-institutional claim.

SHORT NAME: LDEDAMT

LONG NAME: LINE_BENE_PTB_DDCTBL_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 228

LINE_CMS_TYPE_SRVC_CD

LABEL: Line CMS Type Service Code

DESCRIPTION: Code indicating the type of service, as defined in the CMS Medicare carrier Manual, for this line item

on the non-institutional claim.

SHORT NAME: TYPSRVCB

LONG NAME: LINE_CMS_TYPE_SRVC_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES:

1 = Medical care

2 = Surgery

3 = Consultation

4 = Diagnostic radiology

5 = Diagnostic laboratory

6 = Therapeutic radiology

7 = Anesthesia

8 = Assistant at surgery

9 = Other medical items or services

0 = Whole blood

A = Used durable medical equipment

(DME)

D = Ambulance

E = Enteral/parenteral

nutrients/supplies

F = Ambulatory

surgical center

(facility usage for

surgical services)

G = Immunosuppressive drugs

J = Diabetic shoes

K = Hearing items and services

L = ESRD supplies

M = Monthly capitation payment for

dialysis

N = Kidney donor

P = Lump sum purchase of DME,

prosthetics orthotics

Q = Vision items or services

R = Rental of DME

S = Surgical dressings or other medical

supplies

T = Outpatient mental health

limitation

U = Occupational therapy

V = Pneumococcal/flu vaccine

W = Physical therapy

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 229

LINE_COINSRNC_AMT

LABEL: Line Beneficiary Coinsurance Amount

DESCRIPTION: The beneficiary coinsurance liability amount for this line-item service on the non-institutional claim.

This variable is the beneficiary’s liability for coinsurance for the service on the line-item record.

Beneficiaries only face coinsurance once they have satisfied Part B’s annual deductible, which applies

to both institutional (e.g., Hospital outpatient) and non-institutional (e.g., carrier and DME) services.

For most Part B services, coinsurance equals 20 percent of the allowed amount.

SHORT NAME: COINAMT

LONG NAME: LINE_COINSRNC_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: Medicare payments are described in detail in a series called the Medicare Learning Network (MLN)

“Payment System Fact Sheet Series” (reference the list of MLN publications at:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/html/medicare-payment-systems.html).

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 230

LINE_DME_PRCHS_PRICE_AMT

LABEL: Line DME Purchase Price Amount

DESCRIPTION: The amount representing the lower of fee schedule for purchase of new or used DME, or actual

charge. In case of rental DME, this amount represents the purchase cap; rental payments can only be

made until the cap is met.

This line-item field is applicable to non-institutional claims involving DME, prosthetic, orthotic and

supply items, immunosuppressive drugs, parenteral nutrition (PEN), ESRD and oxygen items referred

to as DMEPOS.

SHORT NAME: DME_PURC

LONG NAME: LINE_DME_PRCHS_PRICE_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: —

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 231

LINE_DROP_OFF_ZIP_CD

LABEL: Line Drop Off Zip Code

DESCRIPTION: Line drop off zip code.

SHORT NAME: LINE_DROP_OFF_ZIP_CD

LONG NAME: LINE_DROP_OFF_ZIP_CD

TYPE: CHAR

LENGTH: 5

SOURCE: NCH

VALUES: XXXXX

COMMENT: The drop off zip code is used for pricing ambulance services.

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LINE_HCT_HGB_RSLT_NUM

LABEL: Hematocrit/Hemoglobin Test Results

DESCRIPTION: This is the laboratory value for the most recent hematocrit or hemoglobin reading on the non-

institutional claim.

SHORT NAME: HCTHGBRS

LONG NAME: LINE_HCT_HGB_RSLT_NUM

TYPE: NUM

LENGTH: 4

SOURCE: NCH

VALUES: —

COMMENT: This variable became effective 9/2008 to comply with CR# 5699.

There is a variable to indicate the type of test — whether hematocrit or hemoglobin (variable called

LINE_HCT_HGB_TYPE_CD).

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LINE_HCT_HGB_TYPE_CD

LABEL: Hematocrit/Hemoglobin Test Type Code

DESCRIPTION: The type of test that was performed — hematocrit or hemoglobin.

SHORT NAME: HCTHGBTP

LONG NAME: LINE_HCT_HGB_TYPE_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES: R1 = Hemoglobin Test

R2 = Hematocrit Test

COMMENT: This variable became effective 9/2008 to comply with CR# 5699.

The laboratory value for the test is indicated in the hematocrit/hemoglobin test results field (variable

called LINE_HCT_HGB_RSLT_NUM).

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LINE_ICD_DGNS_CD

LABEL: Line Diagnosis Code

DESCRIPTION: The code indicating the diagnosis supporting this line-item procedure/service on the non-institutional

claim.

SHORT NAME: LINE_ICD_DGNS_CD

LONG NAME: LINE_ICD_DGNS_CD

TYPE: CHAR

LENGTH: 7

SOURCE: NCH

VALUES: —

COMMENT: For ICD-9 diagnosis codes, this is a 3–5 digit numeric or alpha/numeric value; it can include leading

zeros.

On October 1, 2015, the conversion from the 9th version of the International Classification of Diseases

(ICD-9-CM) to version 10 (ICD-10-CM) occurred.

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LINE_ICD_DGNS_VRSN_CD

LABEL: Line Diagnosis Code Diagnosis Version Code (ICD-9 or ICD-10)

DESCRIPTION: Effective with version “J,” the code used to indicate if the diagnosis code is ICD-9/ICD-10.

SHORT NAME: LINE_ICD_DGNS_VRSN_CD

LONG NAME: LINE_ICD_DGNS_VRSN_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: Blank = ICD-9

9 = ICD-9

0 = ICD-10

COMMENT: On October 1, 2015, the conversion from the 9th version of the International Classification of Diseases

(ICD-9-CM) to version 10 (ICD-10-CM) occurred.

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LINE_LAST_EXPNS_DT

LABEL: Line Last Expense Date

DESCRIPTION: The ending date (last expense) for the line-item service on the non-institutional claim.

It is almost always the same as the line-level first expense date (variable called LINE_1ST_EXPNS_DT);

exception is for DME claims — where some services are billed in advance.

SHORT NAME: EXPNSDT2

LONG NAME: LINE_LAST_EXPNS_DT

TYPE: DATE

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: —

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LINE_NCH_PMT_AMT

LABEL: Line NCH Medicare Payment Amount

DESCRIPTION: Amount of payment made from the Medicare trust fund (after deductible and coinsurance amounts

have been paid) for the line-item service on the non-institutional claim.

SHORT NAME: LINEPMT

LONG NAME: LINE_NCH_PMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: —

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LINE_NDC_CD

LABEL: Line National Drug Code (NDC)

DESCRIPTION: On the DMERC claim, the National Drug Code identifying the oral anti-cancer drugs. This line-item field

was added as a placeholder on the carrier claim.

SHORT NAME: LNNDCCD

LONG NAME: LINE_NDC_CD

TYPE: CHAR

LENGTH: 11

SOURCE: NCH

VALUES: —

COMMENT: —

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LINE_NUM

LABEL: Claim Line Number

DESCRIPTION: This variable identifies an individual line number on a claim.

Each revenue center record or claim line has a sequential line number to distinguish distinct services

that are submitted on the same claim.

All revenue center records or claim lines on a given claim have the same CLM_ID.

SHORT NAME: LINE_NUM

LONG NAME: LINE_NUM

TYPE: NUM

LENGTH: 13

SOURCE: CCW

VALUES: —

COMMENT: —

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LINE_OTHR_APLD_AMT1

LINE_OTHR_APLD_AMT2

LINE_OTHR_APLD_AMT3

LINE_OTHR_APLD_AMT4

LINE_OTHR_APLD_AMT5

LINE_OTHR_APLD_AMT6

LINE_OTHR_APLD_AMT7

LABEL: Line Other Applied Amount

DESCRIPTION: The field used to identify amounts that were used to adjust the amount payable when processing the

line item.

SHORT NAME:

LINE_OTHR_APLD_AMT1

LINE_OTHR_APLD_AMT2

LINE_OTHR_APLD_AMT3

LINE_OTHR_APLD_AMT4

LINE_OTHR_APLD_AMT5

LINE_OTHR_APLD_AMT6

LINE_OTHR_APLD_AMT7

LONG NAME:

LINE_OTHR_APLD_AMT1

LINE_OTHR_APLD_AMT2

LINE_OTHR_APLD_AMT3

LINE_OTHR_APLD_AMT4

LINE_OTHR_APLD_AMT5

LINE_OTHR_APLD_AMT6

LINE_OTHR_APLD_AMT7

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: Reference the associated line other applied indicator code in the LINE_OTHR_APLD_IND_CD{#} field.

There are up to seven of these line applied amount fields (LINE_OTHR_APLD_AMT1–

LINE_OTHR_APLD_AMT7).

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LINE_OTHR_APLD_IND_CD1

LINE_OTHR_APLD_IND_CD2

LINE_OTHR_APLD_IND_CD3

LINE_OTHR_APLD_IND_CD4

LINE_OTHR_APLD_IND_CD5

LINE_OTHR_APLD_IND_CD6

LINE_OTHR_APLD_IND_CD7

LABEL: Line Other Applied Indicator Code

DESCRIPTION: The code used to identify the reason the claim payment amount was adjusted during claims

processing.

SHORT NAME:

LINE_OTHR_APLD_IND_CD1

LINE_OTHR_APLD_IND_CD2

LINE_OTHR_APLD_IND_CD3

LINE_OTHR_APLD_IND_CD4

LINE_OTHR_APLD_IND_CD5

LINE_OTHR_APLD_IND_CD6

LINE_OTHR_APLD_IND_CD7

LONG NAME:

LINE_OTHR_APLD_IND_CD1

LINE_OTHR_APLD_IND_CD2

LINE_OTHR_APLD_IND_CD3

LINE_OTHR_APLD_IND_CD4

LINE_OTHR_APLD_IND_CD5

LINE_OTHR_APLD_IND_CD6

LINE_OTHR_APLD_IND_CD7

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES: A = Gramm-Rudman reduction required for services (03/2003/1986–09/30/1986)

B = Interest addition

C = Positive rounding adjustment (due to line-item distribution from total claim reimbursement

amount)

D = Negative rounding adjustment (due to line-item distribution from total claim reimbursement

amount)

E = Primary Payer allowed charge

F = Payment Reduction (Good cause or Late Billing)

G = Payment Reduction (PMDP Demonstration Reduction)

H = Payment Reduction (Sequestration Reduction)

I = Payment Reduction (ePrescribing Negative Adjustment)

J = ACO Payment Adjustment Amount (Pioneer reduction) — the amount that would have been paid if

not for the Pioneer reduction — eff. 1/2014

K = Payment Reduction (ASC Quality Reporting Payment Reduction) — eff. 1/2014

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L = ACO Payment Adjustment Amount (Pioneer reduction) — the actual amount of the Pioneer

reduction — eff. 1/2014

M = Payment Reduction (Physician Quality Reporting System [PQRS] Negative Payment Adjustment) —

eff. 1/2015

N = None (no amount to apply)

O = Negative or Positive Adjustment (Value Based Modifier [VBM] for reduction) — eff. 1/2015

P = Value Based Payment Modifier (VBM) Positive Payment Adjustment — eff. 1/2015

Q = Electronic Health Record (EHR) Negative Payment Adjustment — eff. 1/2015

R = Appropriate/Allowable Co-insurance (4/2023) previous value - Part B Drug Payment Model

(retired)

S = Prior Authorization Reduction — eff. 10/2016

T = Comprehensive Primary Care Plus (CPC+) Payment Adjustment — eff. 4/2017

U = Maryland Primary Care Program (MDPCP) Adjustment — eff. 1/2019

V = Positive Amount for Quality Payment Program (QPP) payment adjustment — eff. 1/2019

W = Negative Amount for Quality Payment Program (QPP) payment adjustment — eff. 1/2019

X = Emergency Triage, Treat, and Transport (ET3) Model Payment — to indicate the amount by which

each line was adjusted for the 15% bonus payment. — eff. 1/2020

Y = Oncology Care Model Plus (OCM+) Population Based Payment Claims Reductions — eff. 1/2020

A2 = Flat Visit Reduction Amount (PCF Model)

A3 = Flat Visit Fee Increased Amount (PCF Model)

A4 = KCF Model Reduction Amount

A5 = CKCC Model Reduction Amount

A6 = Performance Payment Adjustment (PPA) Addition (eff. 1/2022)

A7 = Performance Payment Adjustment (PPA) Reduction (eff. 1/2022)

A8 = Performance Based Adjustment (PBA) Addition (eff. 4/2022)

A9 = Performance Based Adjustment (PBA) Reduction (eff. 4/2022)

B1 = PTA/OTA 15% reduction for Therapy (eff.1/2022)

B2 = Co-Insurance Reduction Amount (eff. 1/2023)

B3 = Monthly Enhanced Oncology Services (MEOS) Positive Payment Adjustment (eff. 4/2023)

B4 = Making Care Primary (MCP) reduction amount

B5 = Performance Based Adjustment (PBA) Positive Amount

B6 = Performance Based Adjustment (PBA) Negative Amount

B7 = Health Equity Adjustment (HEA) Positive Amount

B8 = Health Equity Adjustment (HEA) Negative Amount

COMMENT: Starting in January 2021 with NCH version L, this field was changed from 1 character to 2.

Reference the associated amounts in the LINE_OTHR_APLD_AMT{#} field.

There are up to 7 of these line applied indicator fields (LINE_OTHR_APLD_IND_CD1–

LINE_OTHR_APLD_IND_CD7).

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LINE_PICK_UP_ZIP_CD

LABEL: Line Point of Pickup Zip Code

DESCRIPTION: Line Point of Pickup Zip Code.

SHORT NAME: LINE_POINT_OF_PCKP_ZIP_CD

LONG NAME: LINE_POINT_OF_PCKP_ZIP_CD

TYPE: CHAR

LENGTH: 5

SOURCE: NCH

VALUES: XXXXX

COMMENT: The point of pickup zip code is used for pricing ambulance services.

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LINE_PLACE_OF_SRVC_CD

LABEL: Line Place of Service Code

DESCRIPTION: The code indicating the place of service, as defined in the Medicare carrier manual, for this line item

on the non-institutional claim.

SHORT NAME: PLCSRVC

LONG NAME: LINE_PLACE_OF_SRVC_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES: 01 = Pharmacy — facility or location where drugs and other medically related items and services are

sold, dispensed, or otherwise provided directly to patients

02 = Telehealth provided other than in patient’s home (eff. 1/2017)

03 = School — facility whose primary purpose is education

04 = Homeless shelter — a facility or location whose primary purpose is to provide temporary housing

to homeless individuals (e.g., emergency shelters, individual or family shelters)

05 = Indian health service — free-standing facility. A facility or location, owned and operated by the

Indian health service, which provides diagnostic, therapeutic (surgical and non-surgical), and

rehabilitation services to American Indians and Alaska Natives who do not require hospitalization

06 = Indian health service — provider-based Facility. A facility or location, owned and operated by the

Indian health service, which provides diagnostic, therapeutic (surgical and non-surgical), and

rehabilitation services rendered by, or under the supervision of, physicians to American Indians

and Alaska Natives admitted as inpatients or outpatients

07 = Tribal 638 — free-standing facility. A facility or location owned and operated by a federally

recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement,

which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to

tribal members who do not require hospitalization

08 = Tribal 638 provider-based facility — facility or location owned and operated by a federally

recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement,

which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to

tribal members admitted as inpatients or outpatients

09 = Prison/Correctional facility — prison, jail, reformatory, work farm, detention center, or any other

similar facility maintained by either federal, state, or local authorities for the purpose of

confinement or rehabilitation of adult or juvenile criminal offenders

10 = Unassigned. N/A

11 = Office — location, other than a hospital, skilled nursing facility (SNF), military treatment facility,

community health center, state or local public health clinic, or intermediate care facility (ICF),

where the health professional routinely provides health examinations, diagnosis, and treatment

of illness or injury on an ambulatory basis

12 = Home — location, other than a hospital or other facility, where the patient receives care in a

private residence

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13 = Assisted-living facility — congregate residential facility with self-contained living units providing

assessment of each resident's needs and on-site support 24 hours a day, seven days a week, with

the capacity to deliver or arrange for services including some health care and other services

14 = Group home — residence, with shared living areas, where clients receive supervision and other

services such as social and/or behavioral services, custodial service, and minimal services (e.g.,

medication administration)

15 = Mobile unit — facility/unit that moves from place-to-place equipped to provide preventive,

screening, diagnostic, and/or treatment services

16 = Temporary lodging (eff. 4/2008)

17 = Walk-in retail health clinic. (No later than 5/2010)

18 = Place of employment — worksite. A location, not described by any other POS code, owned, or

operated by a public or private entity where the patient is employed, and where a health

professional provides on-going or episodic occupational medical, therapeutic, or rehabilitative

services to the individual. (This code is available for use eff. January 1, 2013, but no later than

May 1, 2013)

19 = Off campus — outpatient hospital. (eff. 1/2016)

20 = Urgent care facility — location, distinct from a hospital emergency room, an office, or a clinic,

whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients

seeking immediate medical attention

21 = Inpatient hospital — facility, other than psychiatric, which primarily provides diagnostic,

therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the

supervision of physicians to patients admitted for a variety of medical conditions

22 = Outpatient hospital — portion of a hospital which provides diagnostic, therapeutic (both surgical

and nonsurgical), and rehabilitation services to sick or injured persons who do not require

hospitalization or institutionalization

23 = Emergency room — hospital. A portion of a hospital where emergency diagnosis and treatment of

illness or injury is provided

24 = Ambulatory surgical center — freestanding facility, other than a physician's office, where surgical

and diagnostic services are provided on an ambulatory basis

25 = Birthing center — facility, other than a hospital's maternity facilities or a physician's office, which

provides a setting for labor, delivery, and immediate post-partum care as well as immediate care

of newborn infants

26 = Military treatment facility — medical facility operated by one or more of the Uniformed Services.

Military treatment facility (MTF) also refers to certain former U.S. Public Health Service (USPHS)

facilities now designated as Uniformed Service Treatment Facilities (USTF)

27 = Outreach site/Street (eff. 10/2023)

28 = Unassigned. N/A

29 = Unassigned. N/A

30 = Unassigned. N/A

31 = Skilled nursing facility — facility which primarily provides inpatient skilled nursing care and

related services to patients who require medical, nursing, or rehabilitative services but does not

provide the level of care or treatment available in a hospital

32 = Nursing facility — facility which primarily provides to residents skilled nursing care and related

services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-

related care services above the level of custodial care to other than mentally retarded individuals

33 = Custodial care facility — facility which provides room, board, and other personal assistance

services, generally on a long-term basis, and which does not include a medical component

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34 = Hospice. A facility, other than a patient's home, in which palliative and supportive care for

terminally ill patients and their families are provided

35–40 = Unassigned. N/A

41 = Ambulance — land. A land vehicle specifically designed, equipped, and staffed for lifesaving and

transporting the sick or injured

42 = Ambulance — air or water. An air or water vehicle specifically designed, equipped, and staffed for

lifesaving and transporting the sick or injured

43–48 = Unassigned. N/A

49 = Independent clinic — location, not part of a hospital and not described by any other Place of

Service code, that is organized and operated to provide preventive, diagnostic, therapeutic,

rehabilitative, or palliative services to outpatients only. (eff. 10/2003)

50 = Federal Qualified Health Center — facility located in a medically underserved area that provides

Medicare beneficiaries preventive primary medical care under the general direction of a physician

51 = Inpatient psych facility — facility that provides inpatient psychiatric services for the diagnosis and

treatment of mental illness on a 24-hour basis, by or under the supervision of a physician

52 = Psychiatric facility — partial hospitalization. A facility for the diagnosis and treatment of mental

illness that provides a planned therapeutic program for patients who do not require full time

hospitalization, but who need broader programs than are possible from outpatient visits to a

hospital-based or hospital-affiliated facility

53 = Community mental health center — facility that provides the following services: outpatient

services, including specialized outpatient services for children, the elderly, individuals who are

chronically ill, and residents of the CMHC's mental health services area who have been discharged

from inpatient treatment at a mental health facility; 24 hour a day emergency care services; day

treatment, other partial hospitalization services, or psychosocial rehabilitation services; screening

for patients being considered for admission to state mental health facilities to determine the

appropriateness of such admission; and consultation and education services

54 = Intermediate care/Mentally retarded facility — facility which primarily provides health-related

care and services above the level of custodial care to mentally retarded individuals but does not

provide the level of care or treatment available in a hospital or SNF

55 = Residential substance abuse treatment facility — facility which provides treatment for substance

(alcohol and drug) abuse to live-in residents who do not require acute medical care. Services

include individual and group therapy and counseling, family counseling, laboratory tests, drugs

and supplies, psychological testing, and room and board

56 = Psychiatric residential treatment center — facility or distinct part of a facility for psychiatric care

which provides a total 24-hour therapeutically planned and professionally staffed group living and

learning environment

57 = Non-residential substance abuse treatment facility — location which provides treatment for

substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group

therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological

testing

58 = Non-residential opioid treatment facility (eff. 1/2020)

59 = Unassigned. N/A

60 = Mass immunization center — location where providers administer pneumococcal pneumonia and

influenza virus vaccinations and submit these services as electronic media claims, paper claims, or

using the roster billing method. This generally takes place in a mass immunization setting, such

as, a public health center, pharmacy, or mall but may include a physician office setting

61 = Comprehensive inpatient rehabilitation facility — facility that provides comprehensive

rehabilitation services under the supervision of a physician to inpatients with physical disabilities.

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Services include physical therapy, occupational therapy, speech pathology, social or psychological

services, and orthotics and prosthetics services

62 = Comprehensive outpatient rehabilitation facility — facility that provides comprehensive

rehabilitation services under the supervision of a physician to outpatients with physical

disabilities. Services include physical therapy, occupational therapy, and speech pathology

services

63 = Unassigned. N/A

64 = Unassigned. N/A

65 = End-stage renal disease treatment facility — facility other than a hospital, which provides dialysis

treatment, maintenance, and/or training to patients or caregivers on an ambulatory or home-

care basis

66–70 = Unassigned. N/A

71 = Public health clinic — facility maintained by either state or local health departments that provides

ambulatory primary medical care under the general direction of a physician

72 = Rural health clinic — certified facility which is located in a rural medically underserved area that

provides ambulatory primary medical care under the general direction of a physician

73–80 = Unassigned. N/A

81 = Independent laboratory — laboratory certified to perform diagnostic and/or clinical tests

independent of an institution or a physician's office

82–98 = Unassigned. N/A

99 = Other place of service — other place of service not identified above

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 248

LINE_PMT_80_100_CD

LABEL: Line Payment 80%/100% Code

DESCRIPTION: The code indicating that the amount shown in the payment field on the non-institutional line item

represents either 80% or 100% of the allowed charges less any deductible, or 100% limitation of

liability only.

SHORT NAME: PMTINDSW

LONG NAME: LINE_PMT_80_100_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: 0 = 80%

1 = 100%

3 = 100% Limitation of liability only

4 = 75% Reimbursement

COMMENT: —

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LINE_PRCSG_IND_CD

LABEL: Line Processing Indicator Code

DESCRIPTION: The code on a non-institutional claim indicating to whom payment was made or if the claim was

denied.

SHORT NAME: PRCNGIND

LONG NAME: LINE_PRCSG_IND_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES: A = Allowed

B = Benefits exhausted

C = Non-covered care

D = Denied (from BMAD)

G = MSP cost avoided — secondary claims investigation

H = MSP cost avoided — self reports

I = Invalid data

J = MSP cost avoided — 411.25

K = MSP cost avoided — insurer voluntary reporting

L = CLIA

M = Multiple submittal-duplicate line item

N = Medically unnecessary

O = Other

P = Physician ownership denial

Q = MSP cost avoided (contractor #88888) — voluntary agreement

R = Reprocessed adjustments based on subsequent reprocessing of claim

S = Secondary payer

T = MSP cost avoided — IEQ contractor

U = MSP cost avoided — HMO rate cell adjustment

V = MSP cost avoided — litigation settlement

X = MSP cost avoided — generic

Y = MSP cost avoided — IRS/SSA data match project

Z = Bundled test, no payment

00 = MSP cost avoided — COB contractor

12 = MSP cost avoided — BC/BS voluntary agreements

13 = MSP cost avoided — Office of Personnel Management

14 = MSP cost avoided — Workman's Compensation (WC) Datamatch

15 = MSP cost avoided — Workman's Compensation Insurer Voluntary Data Sharing Agreements (WC

VDSA) (eff. 4/2006)

16 = MSP cost avoided — Liability Insurer VDSA (eff.4/2006)

17 = MSP cost avoided — No-Fault Insurer VDSA (eff.4/2006)

18 = MSP cost avoided — Pharmacy Benefit Manager Data Sharing Agreement (eff.4/2006)

21 = MSP cost avoided — MIR Group Health Plan (eff.1/2009)

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22 = MSP cost avoided — MIR non-Group Health Plan (eff.1/2009)

25 = MSP cost avoided — Recovery Audit Contractor — California (eff.10/2005)

26 = MSP cost avoided — Recovery Audit Contractor — Florida (eff.10/2005)

Effective 4/1/2002, the Line Processing Indicator code was expanded to a 2-byte field. The NCH

instituted a crosswalk from the 2-byte code to a 1-byte character code.

Below are the character codes (found in NCH and NMUD). At some point, NMUD will carry the 2-byte

code but NCH will continue to have the 1-byte character code.

! MSP cost avoided — COB Contractor (“00” 2-byte code)

@ MSP cost avoided — BC/BS Voluntary Agreements (“12” 2-byte code)

# MSP cost avoided — Office of Personnel Management (“13” 2-byte code)

$ MSP cost avoided — Workman’s Compensation (WC) Datamatch (“14” 2-byte code)

* MSP cost avoided — Workman's Compensation Insurer Voluntary Data Sharing Agreements (WC

VDSA) (“15” 2-byte code) (eff. 4/2006)

( MSP cost avoided — Liability Insurer VDSA (“16” 2-byte code) (eff. 4/2006)

) MSP cost avoided — No-Fault Insurer VDSA (“17” 2-byte code) (eff. 4/2006)

+ MSP cost avoided — Pharmacy Benefit Manager Data Sharing Agreement (“18” 2-byte code) (eff.

4/2006)

< MSP cost avoided — MIR Group Health Plan (“21” 2-byte code) (eff. 1/2009)

> MSP cost avoided — MIR non-Group Health Plan (“22” 2-byte code) (eff. 1/2009)

% MSP cost avoided — Recovery Audit Contractor — California (“25” 2-byte code) (eff. 10/2005)

& MSP cost avoided — Recovery Audit Contractor — Florida (“26” 2-byte code) (eff. 10/2005)

COMMENT: —

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LINE_PRMRY_ALOWD_CHRG_AMT

LABEL: Line Primary Payer Allowed Charge Amount

DESCRIPTION: The primary payer allowed charge amount for the line-item service on the non-institutional claim.

If there is a primary payer other than Medicare, there may be an allowed payment for the provider; if

so, this field is populated.

SHORT NAME: PRPYALOW

LONG NAME: LINE_PRMRY_ALOWD_CHRG_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: —

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LINE_PRVDR_PMT_AMT

LABEL: Line Provider Payment Amount

DESCRIPTION: The payment made by Medicare to the provider for the line-item service on the non-institutional

claim. Additional payments may have been made to the provider — including beneficiary deductible

and coinsurance amounts and/or other primary payer amounts.

SHORT NAME: LPRVPMT

LONG NAME: LINE_PRVDR_PMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: —

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LINE_PRVDR_VLDTN_TYPE_CD

LABEL: Line Provider Validation Type Code

DESCRIPTION: Line provider validation type code for carrier claim lines

SHORT NAME: LINE_PRVDR_VLDTN_TYPE_CD

LONG NAME: LINE_PRVDR_VLDTN_TYPE_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES: RP = Rendering Provider

OP = Operating Physician

CP = Ordering/ Referring Physician

AP = Attending Physician

FA = Facility

COMMENT: The purpose of the Provider Validation Type field on the claim is to inform Common Working File

(CWF) to perform an edit check to ensure that the provider that was submitted on the prior

authorization (PA) request is the same provider on the claim.

This field was new in April 2019.

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LINE_RA_RMRK_CD

LABEL: Line Remittance Advice Remark Code

DESCRIPTION: Claim remittance advice remark code used to provide an additional explanation for an adjustment

already described by a claim adjustment reason code (CARC) for a claim or claim line. It is also used to

communicate information about remittance processing. This field is currently only populated for

Direct Contracting (DC), Comprehensive Kidney Care Contracting (CKCC) and Kidney Care First (KCF)

model claims.

SHORT NAME: LINE_RA_RMRK_CD

LONG NAME: LINE_RA_RMRK_CD

TYPE: CHAR

LENGTH: 5

SOURCE: NCH

VALUES: This is not a comprehensive list of values; refer to website below for current values and descriptions:

N83 = No appeal rights. Adjudicative decision based on the provisions of a demonstration project.

COMMENT: This code set is an external code set maintained by X12 (www.x12.org/codes). This field is not

populated prior to 2021.

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LINE_RP_IND_CD

LABEL: Line Representative Payee (RP) Indicator Code

DESCRIPTION: Line Representative Payee (RP) Indicator Code

SHORT NAME: LINE_RP_IND_CD

LONG NAME: LINE_RP_IND_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: R = bypass representative payee

COMMENT: This field is used to designate by-passing of the prior authorization processing for claims with a

representative payee when an “R” is present in the field.

Data will not start coming in until April 2016.

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LINE_RR_BRD_EXCLSN_IND_SW

LABEL: Line Railroad Board Exclusion Indicator Switch

DESCRIPTION: This field indicates whether Railroad Board (RRB) beneficiary durable medical equipment (DME) claim

line should be excluded from Prior Authorization (PA) processing.

SHORT NAME: LINE_RR_BRD_EXCLSN_IND_SW

LONG NAME: LINE_RR_BRD_EXCLSN_IND_SW

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: Y = Yes (exclude RRB beneficiary from PA)

Null/missing = Subject RRB beneficiary services to prior authorization

COMMENT: This field informs the SSMs and CWF if the RRB beneficiary claim should either be included or excluded

from Prior Authorization (PA) processing. (e.g., if the field is valued “Y”, and it is RRB beneficiary claim,

it will be excluded from PA processing).

This field was new in April 2019.

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LINE_RSDL_PYMT_IND_CD

LABEL: Line Residual Payment Indicator Code

DESCRIPTION: This field is used by CWF claims processing for the purpose of bypassing its normal MSP editing that

would otherwise apply for ongoing responsibility for medicals (ORM) or worker's compensation

Medicare Set-Aside Arrangements (WCMSA). Normally, CWF does not allow a secondary payment on

MSP involving ORM or WCMSA, so the residual payment indicator is used to allow CWF to make an

exception to its normal routine.

SHORT NAME: LINE_RSDL_PYMT_IND_CD

LONG NAME: LINE_RSDL_PYMT_IND_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: X = Residual Payment

COMMENT: This field was new in April 2016 and is null/missing for all previous years.

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LINE_SBMTD_CHRG_AMT

LABEL: Line Submitted Charge Amount

DESCRIPTION: The amount of submitted charges for the line-item service on the non-institutional claim.

Providers' submitted charges often differ from the amount they were eventually paid — either from

Medicare, the beneficiary (through deductible or coinsurance amounts) or third-party payers.

SHORT NAME: LSBMTCHG

LONG NAME: LINE_SBMTD_CHRG_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: —

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LINE_SERVICE_DEDUCTIBLE

LABEL: Line Service Deductible Indicator Switch

DESCRIPTION: Switch indicating whether or not the line-item service on the non-institutional claim is subject to a

deductible.

SHORT NAME: DED_SW

LONG NAME: LINE_SERVICE_DEDUCTIBLE

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: 0 = Service Subject to Deductible

1 = Service Not Subject to Deductible

COMMENT: —

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LINE_SRVC_CNT

LABEL: Line Service Count

DESCRIPTION: The count of the total number of services processed for the line item on the non-institutional claim.

SHORT NAME: SRVC_CNT

LONG NAME: LINE_SRVC_CNT

TYPE: NUM

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: This field may have decimals (it is formatted as SAS length 11.3).

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 261

LINE_VLNTRY_SRVC_IND_CD

LABEL: Line Voluntary Service Indicator Code

DESCRIPTION: Effective with version “L” of the NCH layout, this line level field will be used to identify if the service

(procedure code) was voluntary or required.

SHORT NAME: LINE_VLNTRY_SRVC_IND_CD

LONG NAME: LINE_VLNTRY_SRVC_IND_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: V = A voluntary procedure code

Null/missing = A required procedure code

COMMENT: This field was new in January 2021.

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LTCH_DSCHRG_PYMT_ADJSTMT_AMT

LABEL: LTCH Discharge Payment Adjustment Amount

DESCRIPTION: Identifies the amount of a long-term care hospital discharge payment percentage adjustment that will

be applied to the payment rate for failure to maintain the required discharge payment percentage.

SHORT NAME: LTCH_DSCHRG_PYMT_ADJSTMT_AMT

LONG NAME: LTCH_DSCHRG_PYMT_ADJSTMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: The adjustment has been applied to the Claim Payment Amount (CLM_PMT_AMT).

This field is new with the NCH version L layout; it is not populated before January 2021.

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MS_DRG_GRPR_VRSN_CD

LABEL: MS-DRG Grouper Version Code

DESCRIPTION: This field displays the Medicare-Severity Diagnosis Related Group (MS-DRG) Grouper version for the

inpatient or skilled nursing facility (SNF) claim.

SHORT NAME: MS_DRG_GRPR_VRSN_CD

LONG NAME: MS_DRG_GRPR_VRSN_CD

TYPE: CHAR

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: This field is not populated prior to 2021. GROUPER is the software that determines the DRG from data

elements reported by the hospital.

Once determined, the DRG code is one of the elements used to determine the price upon which to

base the reimbursement to the hospitals under prospective payment.

Nonpayment claims (zero reimbursement) may not have a DRG present.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 264

NCH_ACTV_OR_CVRD_LVL_CARE_THRU

LABEL: NCH Active or Covered Level Care Thru Date

DESCRIPTION: The date on a claim for which the covered level of care ended in a general hospital or the active care

ended in a psychiatric/tuberculosis hospital.

SHORT NAME: CARETHRU

LONG NAME: NCH_ACTV_OR_CVRD_LVL_CARE_THRU

TYPE: DATE

LENGTH: 8

SOURCE: NCH QA Process

VALUES: —

COMMENT: This variable is derived, using the occurrence code (variable called CLM_RLT_OCRNC_CD), when the

value is 22. When this code value is present the date is populated using the CLM_RLT_OCRNC_DT.

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NCH_BENE_BLOOD_DDCTBL_LBLTY_AM

LABEL: NCH Beneficiary Blood Deductible Liability Amount

DESCRIPTION: The amount of money for which the intermediary determined the beneficiary is liable for the blood

deductible.

A blood deductible amount applies to the first three pints of blood (or equivalent units; applies only to

whole blood or packed red cells — not platelets, fibrinogen, plasma, etc. which are considered

biologicals). However, blood processing is not subject to a deductible. Calculation of the deductible

amount considers both Part A and Part B claims combined. The blood deductible does not count

toward meeting the inpatient hospital deductible or any other applicable deductible and coinsurance

amounts for which the patient is responsible.

SHORT NAME: BLDDEDAM

LONG NAME: NCH_BENE_BLOOD_DDCTBL_LBLTY_AM

TYPE: NUM

LENGTH: 12

SOURCE: NCH QA PROCESS

VALUES: XXX.XX

COMMENT: Costs to beneficiaries are described in detail on the Medicare.gov website. There is a CMS publication

called "Your Medicare Benefits," which explains the blood deductible.

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NCH_BENE_DSCHRG_DT

LABEL: NCH Beneficiary Discharge Date

DESCRIPTION: On an inpatient or home health claim, the date the beneficiary was discharged from the facility, or

died.

Date matches the "thru" date on the claim (CLM_THRU_DT) unless the beneficiary is still a patient (i.e.,

this field is not populated if discharge status code [PTNT_DSCHRG_STUS_CD]= 30 [still a patient]).

When there is a discharge date, the PTNT_DSCHRG_STUS_CD indicates the final disposition of the

patient after discharge.

SHORT NAME: DSCHRGDT

LONG NAME: NCH_BENE_DSCHRG_DT

TYPE: DATE

LENGTH: 8

SOURCE: NCH QA Process

VALUES: —

COMMENT: —

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NCH_BENE_IP_DDCTBL_AMT

LABEL: NCH Beneficiary Inpatient (or other Part A) Deductible Amount

DESCRIPTION: The amount of the deductible the beneficiary paid for inpatient services, as originally submitted on the

institutional claim.

Under Part A, the deductible applies only to inpatient hospital care (whether in an acute care facility,

inpatient psychiatric facility [IPF], inpatient rehabilitation facility [IRF], or long-term care hospital

[LTCH]) and is charged only at the beginning of each benefit period, which is similar to an episode of

illness.

This variable is null/missing for skilled nursing facility (SNF), home health, and hospice claims.

SHORT NAME: DED_AMT

LONG NAME: NCH_BENE_IP_DDCTBL_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: Costs to beneficiaries are described in detail on the Medicare.gov website.

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NCH_BENE_MDCR_BNFTS_EXHTD_DT_I

LABEL: NCH Beneficiary Medicare Benefits Exhausted Date

DESCRIPTION: The last date for which the beneficiary has Medicare coverage.

This is completed only where benefits were exhausted before the date of discharge and during the

billing period covered by this institutional claim.

SHORT NAME: EXHST_DT

LONG NAME: NCH_BENE_MDCR_BNFTS_EXHTD_DT_I

TYPE: DATE

LENGTH: 8

SOURCE: NCH QA process

VALUES: —

COMMENT: Derived from: CLM_RLT_OCRNC_CD and CLM_RLT_OCRNC_DT

Derivation rules: Based on the presence of occurrence code A3, B3, or C3 move the related occurrence

date to NCH_MDCR_BNFT_EXHST_DT.

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NCH_BENE_PTA_COINSRNC_LBLTY_AM

LABEL: NCH Beneficiary Part A Coinsurance Liability Amount

DESCRIPTION: The amount of money for which the intermediary has determined that the beneficiary is liable for Part

A coinsurance on the institutional claim.

Under Part A, beneficiaries pay coinsurance starting with the 61st day of an inpatient hospital stay

(one daily amount for days 61–90, and a higher daily amount for any days after that, which count

towards a beneficiary’s 60 lifetime reserve days) or the 21st day of a skilled nursing facility (SNF) stay

(a daily amount for days 21–100, after which SNF coverage ends).

This variable is null/missing for home health and hospice claims.

SHORT NAME: COIN_AMT

LONG NAME: NCH_BENE_PTA_COINSRNC_LBLTY_AM

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: Costs to beneficiaries are described in detail on the Medicare.gov website.

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NCH_BENE_PTB_COINSRNC_AMT

LABEL: NCH Beneficiary Part B Coinsurance Amount

DESCRIPTION: The amount of money for which the intermediary has determined that the beneficiary is liable for Part

B coinsurance on the institutional claim.

SHORT NAME: PTB_COIN

LONG NAME: NCH_BENE_PTB_COINSRNC_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH QA PROCESS

VALUES: XXX.XX

COMMENT: Derivation Rules: If value codes (variable called CLM_VAL_CD) = A2, B2, or C2, then the related value

amount (variable called CLM_VAL_AMT) is output to this field.

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NCH_BENE_PTB_DDCTBL_AMT

LABEL: NCH Beneficiary Part B Deductible Amount

DESCRIPTION: The amount of money for which the intermediary or carrier has determined that the beneficiary is

liable for the Part B cash deductible on the claim.

SHORT NAME: PTB_DED

LONG NAME: NCH_BENE_PTB_DDCTBL_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH QA PROCESS

VALUES: XXX.XX

COMMENT: Derivation Rules: If value codes (variable called CLM_VAL_CD) = A1, B1, or C1, then the related value

amount (variable called CLM_VAL_AMT) is output to this field.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 272

NCH_BLOOD_PNTS_FRNSHD_QTY

LABEL: NCH Blood Pints Furnished Quantity

DESCRIPTION: Number of whole pints of blood furnished to the beneficiary, as reported on the carrier claim (non-

DMERC).

SHORT NAME: BLDFRNSH

LONG NAME: NCH_BLOOD_PNTS_FRNSHD_QTY

TYPE: NUM

LENGTH: 3

SOURCE: NCH

VALUES: —

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 273

NCH_CARR_CLM_ALOWD_AMT

LABEL: NCH Carrier Claim Allowed Charge Amount (sum of all line-level allowed charges)

DESCRIPTION: The total allowed charges on the claim (the sum of line item allowed charges).

SHORT NAME: ALOWCHRG

LONG NAME: NCH_CARR_CLM_ALOWD_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH QA Process

VALUES: XXX.XX

COMMENT: Sum of all the line LINE_NCH_PMT_AMT values for the claim.

Medicare payments are described in detail in a series of Medicare Payment Advisory Commission

(MedPAC) documents called “Payment Basics” (reference: https://www.medpac.gov/document-

type/payment-basic/).

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (reference:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/html/medicare-payment-systems.html).

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 274

NCH_CARR_CLM_SBMTD_CHRG_AMT

LABEL: NCH Carrier Claim Submitted Charge Amount (sum of all line-level submitted charges)

DESCRIPTION: The total submitted charges on the claim (sum of all line-level submitted charges, variable called

LINE_SBMTD_CHRG_AMT).

SHORT NAME: SBMTCHRG

LONG NAME: NCH_CARR_CLM_SBMTD_CHRG_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH QA Process

VALUES: XXX.XX

COMMENT: The charges the provider submits may be different than the amount that Medicare or a secondary

payer will allow for the claim — and this amount is also different than the actual Medicare or

beneficiary paid amounts.

Medicare payments are described in detail in a series of Medicare Payment Advisory Commission

(MedPAC) documents called “Payment Basics” (reference: https://www.medpac.gov/document-

type/payment-basic/).

Also, in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (reference:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/html/medicare-payment-systems.html).

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 275

NCH_CLM_BENE_PMT_AMT

LABEL: NCH Claim Payment Amount to Beneficiary

DESCRIPTION: The total payments made to the beneficiary for this claim (sum of all line-level payments to

beneficiary, variable called LINE_BENE_PMT_AMT).

SHORT NAME: BENE_PMT

LONG NAME: NCH_CLM_BENE_PMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH QA Process

VALUES: XXX.XX

COMMENT: This variable is populated if, for example, a beneficiary pays for a service that should have been

Medicare-covered.

The beneficiary can be refunded the payment.

Costs to that beneficiaries are liable for are described in detail on the Medicare.gov website. There is a

CMS publication called "Your Medicare Benefits," which explains the deductibles and coinsurance

amounts.

Medicare payments are described in detail in a series of Medicare Payment Advisory Commission

(MedPAC) documents called “Payment Basics” (reference: https://www.medpac.gov/document-

type/payment-basic/).

Also, in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (reference the list

of MLN publications at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/html/medicare-payment-systems.html).

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NCH_CLM_PRVDR_PMT_AMT

LABEL: NCH Claim Provider Payment Amount

DESCRIPTION: The total payments made to the provider for this claim (sum of line-item provider payment amounts

(variable called LINE_PRVDR_PMT_AMT).

SHORT NAME: PROV_PMT

LONG NAME: NCH_CLM_PRVDR_PMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH QA Process

VALUES: XXX.XX

COMMENT: Medicare payments are described in detail in a series of Medicare Payment Advisory Commission

(MedPAC) documents called “Payment Basics” (reference: https://www.medpac.gov/document-

type/payment-basic/).

Also in the Medicare Learning Network (MLN) “Payment System Fact Sheet Series” (reference:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/html/medicare-payment-systems.html).

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 277

NCH_CLM_TYPE_CD

LABEL: NCH Claim Type Code

DESCRIPTION: The type of claim that was submitted. There are different claim types for each major category of

health care provider.

SHORT NAME: CLM_TYPE

LONG NAME: NCH_CLM_TYPE_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES: 10 = Home health agency (HHA) claim

20 = Non swing bed skilled nursing facility (SNF) claim

30 = Swing bed SNF claim

40 = Hospital outpatient claim

50 = Hospice claim

60 = Inpatient claim

71 = Local carrier non-durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claim

72 = Local carrier DMEPOS claim

81 = Durable medical equipment regional carrier (DMERC); non-DMEPOS claim

82 = DMERC; DMEPOS claim

COMMENT: This variable may not always indicate the type of service performed; for example, when the claim type

code = 60 (inpatient), the services may actually be for post-acute care. Additional information

regarding the type of service on the claim can be found in a CCW Technical Guidance document

entitled: "Getting Started with Medicare data".

Note that there is a data issue with the incorrect assignment of National Claims History (NCH) claim

type codes for 37,962 Part B carrier and DMERC (claim type codes 71,72,81,82) claims processed on

01/27/23 (i.e., the NCH_WKLY_PROC_DT). For nearly all of the affected claims, the

NCH_CLM_TYPE_CD was incorrectly assigned an 81 instead of 82; there are also 7 of the total

impacted claims where the NCH_CLM_TPYE_CD was incorrectly assigned 71 instead of 72.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 278

NCH_DRG_OUTLIER_APRVD_PMT_AMT

LABEL: NCH DRG Outlier Approved Payment Amount

DESCRIPTION: On an institutional claim, the additional payment amount approved by the Quality Improvement

Organization due to an outlier situation for a beneficiary's stay under the prospective payment system

(PPS), which has been classified into a specific diagnosis related group (DRG).

This variable will typically include the total outlier payment amount, if any, for the claim.

SHORT NAME: OUTLRPMT

LONG NAME: NCH_DRG_OUTLIER_APRVD_PMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH QA Process

VALUES: —

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 279

NCH_IP_NCVRD_CHRG_AMT

LABEL: NCH Inpatient (or other Part A) Non-covered Charge Amount

DESCRIPTION: The non-covered charges for all accommodations and services, reported on an inpatient claim (used

for internal NCHMQA editing purposes).

SHORT NAME: NCCHGAMT

LONG NAME: NCH_IP_NCVRD_CHRG_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH QA Process

VALUES: XXX.XX

COMMENT: DERIVED FROM:

• REV_CNTR_CD

• REV_CNTR_NCVR_CHRG_AMT

Derivation Rules: Based on the presence of revenue center code equal to 0001, move the related non-

covered charge amount to NCH_IP_NCOV_CHRG_AMT.

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NCH_IP_TOT_DDCTN_AMT

LABEL: NCH Inpatient (or other Part A) Total Deductible/Coinsurance Amount

DESCRIPTION: The total of all Part A and blood deductibles and coinsurance amounts on the claim.

SHORT NAME: TDEDAMT

LONG NAME: NCH_IP_TOT_DDCTN_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH QA Process

VALUES: XXX.XX

COMMENT: Derivation Rules: Accumulate the value amounts (from field called CLM_VAL_AMT) associated with

value codes (CLM_VAL_CD) equal to 06, 08 thru 11 and A1, B1, or C1 and output to this field.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 281

NCH_NEAR_LINE_REC_IDENT_CD

LABEL: NCH Near Line Record Identification Code (RIC)

DESCRIPTION: A code defining the type of claim record being processed.

SHORT NAME: RIC_CD

LONG NAME: NCH_NEAR_LINE_REC_IDENT_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: M = Part B DMEPOS claim record (processed by DME regional carrier)

O = Part B physician/supplier claim record (processed by local carriers; can include DMEPOS services)

U = Both Part A and B institutional home health agency (HHA) claim records

V = Part A institutional claim record (inpatient [IP], skilled nursing facility [SNF], hospice [HOS], or

home health agency [HHA])

W = Part B institutional claim record (outpatient [HOP], HHA)

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 282

NCH_PRMRY_PYR_CLM_PD_AMT

LABEL: NCH Primary Payer (if not Medicare) Claim Paid Amount

DESCRIPTION: The amount of a payment made on behalf of a Medicare beneficiary by a primary payer other than

Medicare, that the provider is applying to covered Medicare charges on a non-institutional claim.

SHORT NAME: PRPAYAMT

LONG NAME: NCH_PRMRY_PYR_CLM_PD_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: Derivation Rules: It is calculated as the sum of the line-level primary payer amounts.

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NCH_PRMRY_PYR_CD

LABEL: NCH Primary Payer Code (if not Medicare)

DESCRIPTION: The code, on an institutional claim, specifying a federal non-Medicare program or other source that

has primary responsibility for the payment of the Medicare beneficiary's health insurance bills.

The presence of a primary payer code indicates that some other payer besides Medicare covered at

least some portion of the charges.

SHORT NAME: PRPAY_CD

LONG NAME: NCH_PRMRY_PYR_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: A = Employer group health plan (EGHP) insurance for an aged beneficiary

B = EGHP insurance for an end-stage renal disease (ESRD) beneficiary

C = Conditional payment by Medicare; future reimbursement from the Public Health Service (PHS)

expected

D = No fault automobile insurance

E = Worker's compensation (WC)

F = Public Health Service (PHS) or other federal agency (other than VA)

G = Working disabled beneficiary under age 65 with a local government health plan (LGHP)

H = Black lung (BL) program

I = Department of Veteran's Affairs

L = Any liability insurance

M = Override EGHP — Medicare is primary payer

N = Override non-EGHP — Medicare is primary payer

Blank /missing = No other primary payer

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 284

NCH_PROFNL_CMPNT_CHRG_AMT

LABEL: Professional Component Charge Amount

DESCRIPTION: This field is the amount of physician and other professional charges covered under Medicare Part B.

SHORT NAME: PCCHGAMT

LONG NAME: NCH_PROFNL_CMPNT_CHRG_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH QA Process

VALUES: XXX.XX

COMMENT: This variable is not populated for home health or hospice claims.

This field is used for CMS editing purposes and other internal processes (e.g., if computing interim

payments, then these charges are deducted).

The source of information for this field for institutional claims is the CLM_VAL_AMT (when the code =

04 or 05, it indicates a professional component charge amount).

For outpatient claims, this information is from the revenue center codes (when the code=096*, 097*

or 098*, then the REV_CNTR_TOT_CHRG_AMT indicates a professional component charge amount).

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NCH_PTNT_STUS_IND_CD

LABEL: NCH Patient Status Indicator Code

DESCRIPTION: This variable is a recoded version of the discharge status code (variable called

PTNT_DSCHRG_STUS_CD).

SHORT NAME: PTNTSTUS

LONG NAME: NCH_PTNT_STUS_IND_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH QA Process

VALUES: A = Discharged

B = Died

C = Still a patient

COMMENT: This field should not be used prior to March 2024 due to inaccuracies in the derivation of this field.

Use the PTNT_DSCHRG_STUS_CD instead.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 286

NCH_QLFYD_STAY_FROM_DT

LABEL: NCH Qualified Stay From Date

DESCRIPTION: The beginning date of the beneficiary's qualifying Medicare stay.

For inpatient claims, the date relates to the PPS portion of the inlier for which there is no utilization of

benefits.

For SNF claims, the date relates to a qualifying stay from a hospital that is at least two days in a row if

the source of admission is an “A” (transfer from critical access hospital), or at least three days in a row

if the source of admission is other than “A”.

SHORT NAME: QLFYFROM

LONG NAME: NCH_QLFYD_STAY_FROM_DT

TYPE: DATE

LENGTH: 8

SOURCE: NCH QA Process

VALUES: —

COMMENT: Derivation Rules: Based on the presence of the occurrence span code (variable called

CLM_OCRNC_SPAN_CD) 70. When this code value is present the date is populated using the

CLM_OCRNC_SPAN_FROM_DT.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 287

NCH_QLFYD_STAY_THRU_DT

LABEL: NCH Qualified Stay Through Date

DESCRIPTION: The ending date of the beneficiary's qualifying Medicare stay.

For inpatient claims, the date relates to the PPS portion of the inlier for which there is no utilization of

benefits.

For SNF claims, the date relates to a qualifying stay from a hospital that is at least two days in a row if

the source of admission is an “A” (transfer from critical access hospital), or at least three days in a row

if the source of admission is other than “A”.

SHORT NAME: QLFYTHRU

LONG NAME: NCH_QLFYD_STAY_THRU_DT

TYPE: DATE

LENGTH: 8

SOURCE: NCH QA Process

VALUES: —

COMMENT: Derivation Rules: Based on the presence of the occurrence span code (variable called

CLM_OCRNC_SPAN_CD) 70. When this code value is present the date is populated using the

CLM_OCRNC_SPAN_THRU_DT.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 288

NCH_VRFD_NCVRD_STAY_FROM_DT

LABEL: NCH Verified Non-covered Stay From Date

DESCRIPTION: The beginning date of the beneficiary's Non-covered stay.

Medicare places limits on the number of days of inpatient or SNF care that a beneficiary may receive.

For some beneficiaries, all days in one of these settings may not be covered by Medicare.

SHORT NAME: NCOVFROM

LONG NAME: NCH_VRFD_NCVRD_STAY_FROM_DT

TYPE: DATE

LENGTH: 8

SOURCE: NCH QA Process

VALUES: —

COMMENT: Derivation Rules: Based on the presence of the occurrence span code (variable called CLM_SPAN_CD)

74, 76, 77, or 79. When this code value is present the date is populated using the

CLM_SPAN_FROM_DT.

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NCH_VRFD_NCVRD_STAY_THRU_DT

LABEL: NCH Verified Non-covered Stay Through Date

DESCRIPTION: The ending date of the beneficiary's non-covered stay.

Medicare places limits on the number of days of inpatient or SNF care that a beneficiary may receive.

For some beneficiaries, all days in one of these settings may not be covered by Medicare.

SHORT NAME: NCOVTHRU

LONG NAME: NCH_VRFD_NCVRD_STAY_THRU_DT

TYPE: DATE

LENGTH: 8

SOURCE: NCH QA Process

VALUES: —

COMMENT: Derivation Rules: Based on the presence of the occurrence span code (variable called CLM_SPAN_CD)

74, 76, 77, or 79. When this code value is present the date is populated using the

CLM_SPAN_THRU_DT.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 290

NCH_WKLY_PROC_DT

LABEL: NCH Weekly Claim Processing Date

DESCRIPTION: The date the weekly NCH database load process cycle begins, during which the claim records are

loaded into the Nearline file. This date will always be a Friday, although the claims will actually be

appended to the database subsequent to the date.

SHORT NAME: WKLY_DT

LONG NAME: NCH_WKLY_PROC_DT

TYPE: DATE

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 291

OP_PHYSN_NPI

LABEL: Claim Operating Physician NPI Number

DESCRIPTION: On an institutional claim, the National Provider Identifier (NPI) number assigned to uniquely identify

the physician with the primary responsibility for performing the surgical procedure(s).

NPIs replaced UPINs as the standard provider identifiers beginning in 2007. The UPIN is almost never

populated after 2009.

SHORT NAME: OP_NPI

LONG NAME: OP_PHYSN_NPI

TYPE: CHAR

LENGTH: 10

SOURCE: NCH

VALUES: —

COMMENT: CMS has determined that dual provider identifiers (old legacy numbers and new NPI) must be

available in the NCH. After the 5/2007 NPI implementation, the standard system maintainers will add

the legacy number to the claim when it is adjudicated. We will continue to receive the OSCAR provider

number and any currently issued UPINs. Effective May 2007, no new UPINs (legacy numbers) will be

generated for new physicians (Part B and outpatient claims), so there will only be NPIs sent into the

NCH for those physicians.

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OP_PHYSN_SPCLTY_CD

LABEL: Claim Operating Physician Specialty Code

DESCRIPTION: The code used to identify the CMS specialty code corresponding to the operating physician. The

Affordable Care Act (ACA) provides for incentive payments for physicians and non-physician

practitioners with specific primary specialty designations. In order to determine if the physician or

non-physicians is eligible for the incentive payment, the specialty code, NPI and name must be carried

on the claims.

SHORT NAME: OP_PHYSN_SPCLTY_CD

LONG NAME: OP_PHYSN_SPCLTY_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES:

00 = Carrier wide

01 = General practice

02 = General surgery

03 = Allergy/immunology

04 = Otolaryngology

05 = Anesthesiology

06 = Cardiology

07 = Dermatology

08 = Family practice

09 = Interventional Pain Management

(IPM) (eff. 4/2003)

10 = Gastroenterology

11 = Internal medicine

12 = Osteopathic manipulative

medicine

13 = Neurology

14 = Neurosurgery

15 = Speech/language pathologist in

private practice

16 = Obstetrics/gynecology

17 = Hospice and Palliative Care

18 = Ophthalmology

19 = Oral surgery (dentists only)

20 = Orthopedic surgery

21 = Cardiac Electrophysiology

22 = Pathology

23 = Sports medicine

24 = Plastic and reconstructive surgery

25 = Physical medicine and rehabilitation

26 = Psychiatry

27 = Geriatric Psychiatry

28 = Colorectal surgery (formerly

proctology)

29 = Pulmonary disease

30 = Diagnostic radiology

31 = Intensive cardiac rehabilitation

32 = Anesthesiologist Assistant (eff.

4/2003 — previously grouped with

Certified Registered Nurse

Anesthetists (CRNA))

33 = Thoracic surgery

34 = Urology

35 = Chiropractic

36 = Nuclear medicine

37 = Pediatric medicine

38 = Geriatric medicine

39 = Nephrology

40 = Hand surgery

41 = Optometry

42 = Certified nurse midwife

43 = Certified Registered Nurse

Anesthetist (CRNA) (Anesthesiologist

Assistants were removed from this

specialty 4/2003)

44 = Infectious disease

45 = Mammography screening center

46 = Endocrinology

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47 = Independent Diagnostic Testing

Facility (IDTF)

48 = Podiatry

49 = Ambulatory surgical center

(formerly miscellaneous)

50 = Nurse practitioner

51 = Medical supply company with

certified orthotist (certified by

American Board for Certification

in Prosthetics and Orthotics)

52 = Medical supply company with

certified prosthetist (certified by

American Board for Certification

in Prosthetics and Orthotics)

53 = Medical supply company with

certified prosthetist-orthotist

(certified by American Board for

Certification in Prosthetics and

Orthotics)

54 = Medical supply company for

DMERC (and not included in 51–

53)

55 = Individual certified orthotic

personnel certified by an

accrediting organization

56 = Individual certified prosthetic

personnel certified by an

accrediting organization

57 = Individual certified prosthetic-

orthotic personnel certified by an

accrediting organization

58 = Medical supply company with

registered pharmacist

59 = Ambulance service (private)

60 = Public health or welfare agencies

(federal, state, and local)

61 = Voluntary health or charitable

agencies (e.g., National Cancer

Society, National Heart

Association, Catholic Charities)

62 = Psychologist (billing

independently)

63 = Portable X-ray supplier (billing

independently)

64 = Audiologist (billing independently)

65 = Physical therapist in private

practice

66 = Rheumatology

67 = Occupational therapist in private

practice

68 = Clinical psychologist

69 = Clinical laboratory (billing

independently)

70 = Single or Multispecialty clinic or

group practice (PA Group)

71 = Registered Dietician/Nutrition

Professional (eff. 1/2002)

72 = Pain Management (eff. 1/2002)

73 = Mass Immunization Roster Biller

74 = Radiation Therapy Centers (prior

to 4/2003 this included

Independent Diagnostic Testing

Facilities (IDTF)

75 = Slide Preparation Facilities (added

to differentiate them from

Independent Diagnostic Testing

Facilities (IDTFs — eff. 4/2003)

76 = Peripheral vascular disease

77 = Vascular surgery

78 = Cardiac surgery

79 = Addiction medicine

80 = Licensed clinical social worker

81 = Critical care (intensivists)

82 = Hematology

83 = Hematology/oncology

84 = Preventive medicine

85 = Maxillofacial surgery

86 = Neuropsychiatry

87 = All other suppliers (e.g., drug

stores)

88 = Unknown provider

89 = Certified clinical nurse specialist

90 = Medical oncology

91 = Surgical oncology

92 = Radiation oncology

93 = Emergency medicine

94 = Interventional radiology

95 = Competitive Acquisition Program

(CAP) Vendor (eff. 07/2001/2006).

Prior to 07/2001/2006, known as

Independent physiological

laboratory

96 = Optician

97 = Physician assistant

98 = Gynecological/oncology

99 = Unknown physician specialty

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A0 = Hospital (DMERCs only)

A1 = Skilled nursing facility (DMERCs

only)

A2 = Intermediate care nursing facility

(DMERCs only)

A3 = Nursing facility, other (DMERCs

only)

A4 = Home health agency (DMERCs

only)

A5 = Pharmacy (DMERC)

A6 = Medical supply company with

respiratory therapist (DMERCs

only)

A7 = Department store (DMERC)

A8 = Grocery store (DMERC)

A9 = Indian Health Service (IHS), tribe

and tribal organizations (non-

hospital or non-hospital-based

facilities, eff. 1/2005)

B1 = Supplier of oxygen and/or oxygen

related equipment (eff.

10/2/2007)

B2 = Pedorthic Personnel (eff.

10/2/2007)

B3 = Medical Supply Company with

pedorthic personnel (eff.

10/2/2007)

B4 = Does not meet definition of

health care provider (e.g.,

Rehabilitation agency, organ

procurement organizations,

histocompatibility labs) (eff.

10/2/2007)

B5 = Ocularist

C0 = Sleep medicine

C1 = Centralized flu

C2 = Indirect payment procedure

C3 = Interventional cardiology

C5 = Dentist (eff. 7/2016)

C6 = Hospitalist

C7 = Advanced heart failure and transplant

cardiology

C8 = Medical toxicology

C9 = Hematopoietic cell transplantation and

cellular therapy

D3 = Medical genetics and genomics

D4 = Undersea and hyperbaric medicine

D5 = Opioid treatment program (eff. 1/2020)

D7 = Micrographic dermatologic surgery

(MDS) (eff. 10/2020)

D8 = Adult congenital heart disease

E1 = Marriage and family therapists

E2 = Mental health counselors

E3 = Dental anesthesiology

E4 = Dental public health

E5 = Endodontics

E6 = Oral and maxillofacial pathology

E7 = Oral and maxillofacial radiology

E9 = Oral medicine

F1 = Orofacial pain

F2 = Orthodontics and dentofacial orthopedics

F3 = Pediatric dentistry

F4 = Periodontics

F5 = Prosthodontics

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 295

OP_PHYSN_UPIN

LABEL: Claim Operating Physician UPIN Number

DESCRIPTION: On an institutional claim, the unique physician identification number (UPIN) of the physician who

performed the principal procedure. This element is used by the provider to identify the operating

physician who performed the surgical procedure.

NPIs replaced UPINs as the standard provider identifiers beginning in 2007. The UPIN is almost never

populated after 2009.

SHORT NAME: OP_UPIN

LONG NAME: OP_PHYSN_UPIN

TYPE: CHAR

LENGTH: 6

SOURCE: NCH

VALUES: —

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 296

ORDRG_PHYSN_NPI

LABEL: Revenue Center Ordering Physician NPI

DESCRIPTION: Effective with version “L” of the NCH layout, this line level field identifies the ordering physician’s

National Provider Identifier (NPI).

SHORT NAME: ORDRG_PHYSN_NPI

LONG NAME: ORDRG_PHYSN_NPI

TYPE: CHAR

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: This field was new in January 2021.

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ORG_NPI_NUM

LABEL: Organization (or group) NPI Number

DESCRIPTION: The National Provider Identifier (NPI) of the organization or group practice.

SHORT NAME: ORGNPINM

LONG NAME: ORG_NPI_NUM

TYPE: CHAR

LENGTH: 10

SOURCE: NCH

VALUES: —

COMMENT: On an institutional claim, this is the NPI number assigned to uniquely identify the institutional provider

certified by Medicare to provide services to the beneficiary.

On the carrier claim, this is line-level information regarding the performing physician (Short Name =

PRGRPNPI); it is the NPI of the group practice, where the performing physician is part of that group.

^ Back to TOC ^

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 298

OT_PHYSN_NPI

LABEL: Claim Other Physician NPI Number

DESCRIPTION: On an institutional claim, the National Provider Identifier (NPI) number assigned to uniquely identify

the other physician associated with the institutional claim.

NPIs replaced UPINs as the standard provider identifiers beginning in 2007. The UPIN is almost never

populated after 2009.

SHORT NAME: OT_NPI

LONG NAME: OT_PHYSN_NPI

TYPE: CHAR

LENGTH: 10

SOURCE: NCH

VALUES: —

COMMENT: CMS has determined that dual provider identifiers (old legacy numbers and new NPI) must be

available in the NCH. After the 5/2007 NPI implementation, the standard system maintainers will add

the legacy number to the claim when it is adjudicated. We will continue to receive the OSCAR provider

number and any currently issued UPINs. Effective May 2007, no new UPINs (legacy numbers) will be

generated for new physicians (Part B and outpatient claims), so there will only be NPIs sent into the

NCH for those physicians.

^ Back to TOC ^

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 299

OT_PHYSN_SPCLTY_CD

LABEL: Claim Other Physician Specialty Code

DESCRIPTION: The code used to identify the CMS specialty code corresponding to the other physician.

SHORT NAME: OT_PHYSN_SPCLTY_CD

LONG NAME: OT_PHYSN_SPCLTY_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES:

00 = Carrier wide

01 = General practice

02 = General surgery

03 = Allergy/immunology

04 = Otolaryngology

05 = Anesthesiology

06 = Cardiology

07 = Dermatology

08 = Family practice

09 = Interventional pain management

(IPM) (eff. 4/2003)

10 = Gastroenterology

11 = Internal medicine

12 = Osteopathic manipulative

medicine

13 = Neurology

14 = Neurosurgery

15 = Speech/language pathologist in

private practice

16 = Obstetrics/gynecology

17 = Hospice and palliative care

18 = Ophthalmology

19 = Oral surgery (dentists only)

20 = Orthopedic surgery

21 = Cardiac electrophysiology

22 = Pathology

23 = Sports medicine

24 = Plastic and reconstructive surgery

25 = Physical medicine and

rehabilitation

26 = Psychiatry

27 = Geriatric psychiatry

28 = Colorectal surgery (formerly

proctology)

29 = Pulmonary disease

30 = Diagnostic radiology

31 = Intensive cardiac rehabilitation

32 = Anesthesiologist Assistant (eff.

4/2003 — previously grouped with

Certified Registered Nurse

Anesthetists (CRNA))

33 = Thoracic surgery

34 = Urology

35 = Chiropractic

36 = Nuclear medicine

37 = Pediatric medicine

38 = Geriatric medicine

39 = Nephrology

40 = Hand surgery

41 = Optometry

42 = Certified nurse midwife

43 = Certified Registered Nurse

Anesthetist (CRNA)

(Anesthesiologist Assistants were

removed from this specialty

4/2003)

44 = Infectious disease

45 = Mammography screening center

46 = Endocrinology

47 = Independent diagnostic testing

facility (IDTF)

48 = Podiatry

49 = Ambulatory surgical center

(formerly miscellaneous)

50 = Nurse practitioner

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51 = Medical supply company with

certified orthotist (certified by

American Board for Certification

in Prosthetics and Orthotics)

52 = Medical supply company with

certified prosthetist (certified by

American Board for Certification

in Prosthetics and Orthotics)

53 = Medical supply company with

certified prosthetist-orthotist

(certified by American Board for

Certification in Prosthetics and

Orthotics)

54 = Medical supply company for

DMERC (and not included in 51–

53)

55 = Individual certified orthotic

personnel certified by an

accrediting organization

56 = Individual certified prosthetic

personnel certified by an

accrediting organization

57 = Individual certified prosthetic-

orthotic personnel certified by an

accrediting organization

58 = Medical supply company with

registered pharmacist

59 = Ambulance service (private)

60 = Public health or welfare agencies

(federal, state, and local)

61 = Voluntary health or charitable

agencies (e.g., National Cancer

Society, National Heart

Association, Catholic Charities)

62 = Psychologist (billing

independently)

63 = Portable X-ray supplier (billing

independently)

64 = Audiologist (billing independently)

65 = Physical therapist in private

practice

66 = Rheumatology

67 = Occupational therapist in private

practice

68 = Clinical psychologist

69 = Clinical laboratory (billing

independently)

70 = Single or Multispecialty clinic or

group practice (PA Group)

71 = Registered Dietician/Nutrition

Professional (eff. 1/2002)

72 = Pain Management (eff. 1/2002)

73 = Mass Immunization Roster Biller

74 = Radiation Therapy Centers (prior to

4/2003 this included Independent

Diagnostic Testing Facilities (IDTF)

75 = Slide Preparation Facilities (added

to differentiate them from

Independent Diagnostic Testing

Facilities (IDTFs — eff. 4/2003)

76 = Peripheral vascular disease

77 = Vascular surgery

78 = Cardiac surgery

79 = Addiction medicine

80 = Licensed clinical social worker

81 = Critical care (intensivists)

82 = Hematology

83 = Hematology/oncology

84 = Preventive medicine

85 = Maxillofacial surgery

86 = Neuropsychiatry

87 = All other suppliers (e.g., drug

stores)

88 = Unknown provider

89 = Certified clinical nurse specialist

90 = Medical oncology

91 = Surgical oncology

92 = Radiation oncology

93 = Emergency medicine

94 = Interventional radiology

95 = Competitive Acquisition Program

(CAP) Vendor (eff. 07/2001/2006).

Prior to 07/2001/2006, known as

Independent physiological

laboratory

96 = Optician

97 = Physician assistant

98 = Gynecological/oncology

99 = Unknown physician specialty

A0 = Hospital (DMERCs only)

A1 = Skilled nursing facility (DMERCs

only)

A2 = Intermediate care nursing facility

(DMERCs only)

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A3 = Nursing facility, other (DMERCs

only)

A4 = Home health agency (DMERCs

only)

A5 = Pharmacy (DMERC)

A6 = Medical supply company with

respiratory therapist (DMERCs

only)

A7 = Department store (DMERC)

A8 = Grocery store (DMERC)

A9 = Indian Health Service (IHS), tribe

and tribal organizations (non-

hospital or non-hospital-based

facilities, eff. 1/2005)

B1 = Supplier of oxygen and/or oxygen

related equipment (eff. 10/2007)

B2 = Pedorthic Personnel (eff.

10/2007)

B3 = Medical Supply Company with

pedorthic personnel (eff.

10/2007)

B4 = Does not meet definition of

health care provider (e.g.,

Rehabilitation agency, organ

procurement organizations,

histocompatibility labs) (eff.

10/2/2007)

B5 = Ocularist

C0 = Sleep medicine

C1 = Centralized flu

C2 = Indirect payment procedure

C3 = Interventional

cardiology

C5 = Dentist (eff. 7/2016)

C6 = Hospitalist

C7 = Advanced heart failure and

transplant cardiology

C8 = Medical toxicology

C9 = Hematopoietic cell

transplantation and cellular

therapy

D3 = Medical genetics and genomics

D4 = Undersea and hyperbaric

medicine

D5 = Opioid treatment program (eff.

1/2020)

D7 = Micrographic dermatologic surgery

(MDS) (eff. 10/2020)

D8 = Adult congenital heart disease

E1 = Marriage and family therapists

E2 = Mental health counselors

E3 = Dental anesthesiology

E4 = Dental public health

E5 = Endodontics

E6 = Oral and maxillofacial pathology

E7 = Oral and maxillofacial radiology

E9 = Oral medicine

F1 = Orofacial pain

F2 = Orthodontics and dentofacial orthopedics

F3 = Pediatric dentistry

F4 = Periodontics

F5 = Prosthodontics

COMMENT: The Affordable Care Act (ACA) provides for incentive payments for physicians and non-physician

practitioners with specific primary specialty designations. In order to determine if the physician or

non-physician is eligible for the incentive payment, the specialty code, NPI and name must be carried

on the claims.

^ Back to TOC ^

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 302

OT_PHYSN_UPIN

LABEL: Claim Other Physician UPIN Number

DESCRIPTION: On an institutional claim, the unique physician identification number (UPIN) of the other physician

associated with the institutional claim.

NPIs replaced UPINs as the standard provider identifiers beginning in 2007. The UPIN is almost never

populated after 2009.

SHORT NAME: OT_UPIN

LONG NAME: OT_PHYSN_UPIN

TYPE: CHAR

LENGTH: 6

SOURCE: NCH

VALUES: —

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 303

OWNG_PRVDR_TIN_NUM

LABEL: Owning Provider Tax Identification Number (TIN)

DESCRIPTION: The tax identification number (TIN) of the hospital provider used to identify ownership. Medicare’s

three-day (or one-day) payment window applies to outpatient services furnished by hospitals and

hospitals wholly owned or wholly operated Part B entities.

SHORT NAME: OWNG_PRVDR_TIN_NUM

LONG NAME: OWNG_PRVDR_TIN_NUM

TYPE: CHAR

LENGTH: 10

SOURCE: NCH

VALUES: —

COMMENT: This field is not populated prior to 2021. Applies to hospital, types of bill (TOBs) 011x, 013x, and 014x,

claims transmitted to CWF on Effective and Term dates, when the Ownership type equals “1” (Hospital

TIN is Owner) or “2” (Owned by different Hospital TIN). The Medicare contractor shall pass to CWF the

Provider’s TIN in the “Owning TIN” field, when the “Ownership Type” field is blank, with all hospital

011x claims transmitted to CWF on Effective and Term dates.

The TOB is the concatenation of two variables:

Facility type (CLM_FAC_TYPE_CD)

Service classification type (CLM_SRVC_CLSFCTN_TYPE_CD).

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 304

PHYSN_ZIP_CD

LABEL: Line Place of Service (POS) Physician Zip Code

DESCRIPTION: The 9-digit zip code for the primary practice/business location of the physician receiving the payment

or other transfer of value.

SHORT NAME: PHYSN_ZIP_CD

LONG NAME: PHYSN_ZIP_CD

TYPE: CHAR

LENGTH: 15

SOURCE: NCH

VALUES: —

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 305

PPS_STD_VAL_PYMT_AMT

LABEL: Standard Payment Amount

DESCRIPTION: This amount identifies the standardized Medicare payment amount.

SHORT NAME: PPS_STD_VAL_PYMT_AMT

LONG NAME: PPS_STD_VAL_PYMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: This is the standardized amount as determined by PRICER software output. This amount is never used

for payments. It is used for comparisons across different regions of the country for the value-based

purchasing initiatives and for research. It is a standard amount, without the geographical payment

adjustments and some of the other add-on payments that actually go to the hospitals.

This field is new in October 2014. This field applied only to inpatient claims until July 2018, when it

also applied to home health agency (HHA) claims. For HHA claims, this field was initially called

FINL_STD_AMT in the CCW RIF.

NOTE: An additional field is available that further adjusts the standard Medicare Payment amount by

applying additional standardization requirements (e.g., sequestration). Refer to variable called the

final standardized amount (FINL_STD_AMT).

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PRCDR_DT1

PRCDR_DT2

PRCDR_DT3

PRCDR_DT4

PRCDR_DT5

PRCDR_DT6

PRCDR_DT7

PRCDR_DT8

PRCDR_DT9

PRCDR_DT10

PRCDR_DT11

PRCDR_DT12

PRCDR_DT13

PRCDR_DT14

PRCDR_DT15

PRCDR_DT16

PRCDR_DT17

PRCDR_DT18

PRCDR_DT19

PRCDR_DT20

PRCDR_DT21

PRCDR_DT22

PRCDR_DT23

PRCDR_DT24

PRCDR_DT25

LABEL: Claim Procedure Code Date

DESCRIPTION: The date on which the procedure was performed. The date associated with the procedure identified in

the corresponding ICD_PRCDR_CD#.

SHORT NAME:

PRCDR_DT1

PRCDR_DT2

PRCDR_DT3

PRCDR_DT4

PRCDR_DT5

PRCDR_DT6

PRCDR_DT7

PRCDR_DT8

PRCDR_DT9

PRCDR_DT10

PRCDR_DT11

PRCDR_DT12

PRCDR_DT13

PRCDR_DT14

PRCDR_DT15

PRCDR_DT16

PRCDR_DT17

PRCDR_DT18

PRCDR_DT19

PRCDR_DT20

PRCDR_DT21

PRCDR_DT22

PRCDR_DT23

PRCDR_DT24

PRCDR_DT25

LONG NAME:

PRCDR_DT1

PRCDR_DT2

PRCDR_DT3

PRCDR_DT4

PRCDR_DT5

PRCDR_DT6

PRCDR_DT7

PRCDR_DT8

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PRCDR_DT9

PRCDR_DT10

PRCDR_DT11

PRCDR_DT12

PRCDR_DT13

PRCDR_DT14

PRCDR_DT15

PRCDR_DT16

PRCDR_DT17

PRCDR_DT18

PRCDR_DT19

PRCDR_DT20

PRCDR_DT21

PRCDR_DT22

PRCDR_DT23

PRCDR_DT24

PRCDR_DT25

TYPE: DATE

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: —

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 308

PRF_PHYSN_NPI

LABEL: Carrier Line Performing NPI Number

DESCRIPTION: The National Provider Identifier (NPI) assigned to the performing provider.

SHORT NAME: PRFNPI

LONG NAME: PRF_PHYSN_NPI

TYPE: CHAR

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: Effective May 2007, the NPI became the national standard identifier for covered health care providers.

NPIs replaced the legacy numbers (UPINs, PINs, etc.) on the standard HIPPA claim transactions.

The UPIN is almost never populated after 2009.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 309

PRF_PHYSN_UPIN

LABEL: Carrier Line Performing UPIN Number

DESCRIPTION: The unique physician identification number (UPIN) of the physician who performed the service for this

line item on the carrier claim (non-DMERC).

NPIs replaced UPINs as the standard provider identifiers beginning in 2007. The UPIN is almost never

populated after 2009.

SHORT NAME: PRF_UPIN

LONG NAME: PRF_PHYSN_UPIN

TYPE: CHAR

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: —

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 310

PRNCPAL_DGNS_CD

LABEL: Claim Principal Diagnosis Code

DESCRIPTION: The diagnosis code identifying the diagnosis, condition, problem, or other reason for the

admission/encounter/visit shown in the medical record to be chiefly responsible for the services

provided.

This data is also redundantly stored as the first occurrence of the diagnosis code (variable called

ICD_DGNS_CD1).

SHORT NAME: PRNCPAL_DGNS_CD

LONG NAME: PRNCPAL_DGNS_CD

TYPE: CHAR

LENGTH: 7

SOURCE: NCH

VALUES: —

COMMENT: Starting in 2011, with version J of the NCH claim layout, institutional claims can have up to 25

diagnosis codes (previously only 11 were accommodated), and the non-institutional claims can have

up to 12 diagnosis codes (previously only up to 8).

Effective with version “J,” this field has been expanded from 5 bytes to 7 bytes to accommodate ICD-

10.

On October 1, 2015, the conversion from the 9th version of the International Classification of Diseases

(ICD-9-CM) to version 10 (ICD-10-CM) occurred.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 311

PRNCPAL_DGNS_VRSN_CD

LABEL: Claim Principal Diagnosis Version Code

DESCRIPTION: Effective with version “J,” the code used to indicate if the diagnosis code is ICD-9/ICD-10.

SHORT NAME: PRNCPAL_DGNS_VRSN_CD

LONG NAME: PRNCPAL_DGNS_VRSN_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: Blank = ICD-9

9 = ICD-9

0 = ICD-10

COMMENT: With 5010, the diagnosis and procedure codes have been expanded to accommodate ICD-10.

On October 1, 2015, the conversion from the 9th version of the International Classification of Diseases

(ICD-9-CM) to version 10 (ICD-10-CM) occurred.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

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PRTCPTNG_IND_CD

LABEL: Line Provider Participating Indicator Code

DESCRIPTION: Code indicating whether or not a provider is participating (accepting assignment) for this line-item

service on the non-institutional claim.

SHORT NAME: PRTCPTG

LONG NAME: PRTCPTNG_IND_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: 1 = Participating

2 = All or some covered and allowed expenses applied to deductible participating

3 = Assignment accepted/non-participating

4 = Assignment not accepted/non-participating

5 = Assignment accepted but all or some covered and allowed expenses applied to deductible non-

participating

6 = Assignment not accepted and all covered and allowed expenses applied to deductible non-

participating

7 = Participating provider not accepting assignment

COMMENT: —

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

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PRVDR_FULL_CCN_NUM

LABEL: Full CMS Certification Number for Provider

DESCRIPTION: This variable is the extended CMS Certification Number (CCN).

This extended field is designed to allow for the identification of multiple campus hospitals. For multi-

campus hospitals, all campuses contain the same first 6-digit CCN (reference PRVDR_NUM variable in

this data file), but positions 7–13 may be used to distinguish between campuses (ex. 01, 02, 001, 002,

A, etc.) In the future positions 7–13 may have other uses.

SHORT NAME: PRVDR_FULL_CCN_NUM

LONG NAME: PRVDR_FULL_CCN_NUM

TYPE: CHAR

LENGTH: 13

SOURCE: NCH (derived)

VALUES: —

COMMENT: NCH will continue to map the positions 1–6 of the provider number to the provider number

(PRVDR_NUM) field.

This field is not populated prior to 2021.

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PRVDR_NPI

LABEL: DMERC Line-Item Supplier NPI Number

DESCRIPTION: The National Provider Identifier (NPI) assigned to the supplier of the Part B service/DMEPOS line item.

NPIs replaced UPINs as the standard provider identifiers beginning in 2007. The UPIN is almost never

populated after 2009.

SHORT NAME: SUP_NPI

LONG NAME: PRVDR_NPI

TYPE: CHAR

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 315

PRVDR_NUM (Institutional claim)

LABEL: Provider Number

DESCRIPTION: This variable is the provider identification number of the institutional provider certified by Medicare to

provide services to the beneficiary. This is the CMS Certification Number (CCN).

The first two digits indicate the state where the provider is located. As two-digit state codes have been

exhausted, CMS has implemented a two-position alpha-numeric coding system for state Codes

(reference the note in the VALUES below). The middle two characters indicate the type of provider;

and the last two digits are used as a counter for the number of providers within that state and type of

provider (i.e., this is a unique but not necessarily sequential number).

SHORT NAME: PROVIDER

LONG NAME: PRVDR_NUM

TYPE: CHAR

LENGTH: 6

SOURCE: —

VALUES: The first two positions are the CCN state codes. A state may have more than one code. The following is

a list of all CMS assigned state codes to be used with the CCN:

00 = Arizona

01 = Alabama

02 = Alaska

03 = Arizona

04 = Arkansas

05 = California

06 = Colorado

07 = Connecticut

08 = Delaware

09 = District of Columbia

10 = Florida

11 = Georgia

12 = Hawaii

13 = Idaho

14 = Illinois

15 = Indiana

16 = Iowa

17 = Kansas

18 = Kentucky

19 = Louisiana

20 = Maine

21 = Maryland

22 = Massachusetts

23 = Michigan

24 = Minnesota

25 = Mississippi

26 = Missouri

27 = Montana

28 = Nebraska

29 = Nevada

30 = New Hampshire

31 = New Jersey

32 = New Mexico

33 = New York

34 = North Carolina

35 = North Dakota

36 = Ohio

37 = Oklahoma

38 = Oregon

39 = Pennsylvania

40 = Puerto Rico

41 = Rhode Island

42 = South Carolina

43 = South Dakota

44 = Tennessee

45 = Texas

46 = Utah

47 = Vermont

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48 = Virgin Islands

49 = Virginia

50 = Washington

51 = West Virginia

52 = Wisconsin

53 = Wyoming

54 = Idaho

55 = California

56 = Canada

57 = New York

58 = West Virginia

59 = Mexico

64 = American Samoa

65 = Guam

66 = Commonwealth of the Northern

Marianas Islands

67 = Texas

68 = Florida

69 = Florida

70 = Kansas

71 = Louisiana

72 = Ohio

73 = Pennsylvania

74 = Texas

75 = California

76 = Iowa

77 = Minnesota

78 = Illinois

79 = Missouri

80 = Maryland

81 = Connecticut

82 = Massachusetts

83 = New Jersey

84 = Puerto Rico

85 = Georgia

86 = North Carolina

87 = South Carolina

88 = Tennessee

89 = Arkansas

90 = Oklahoma

91 = Colorado

92 = California

93 = Oregon

94 = Washington

95 = Louisiana

96 = New Mexico

97 = Texas

98 = Hawaii

99 = Foreign Countries (exceptions: Canada

and Mexico)

A0 = California

A1 = California

A2 = Florida

A3 = Louisiana

A4 = Michigan

A5 = Mississippi

A6 = Ohio

A7 = Pennsylvania

A8 = Tennessee

A9 = Texas

B0 = Kentucky

B1 = West Virginia

B2 = California

B3 = California

B4 = California

B5 = California

B6 = North Carolina

B7 = Alabama

B8 = Commonwealth of the Northern

Marianas Islands

B9 = Delaware

C0 = District of Columbia

C1 = Florida

C2 = Georgia

C3 = Guam

C4 = Illinois

C5 = Indiana

C6 = Maine

C7 = Michigan

C8 = Mississippi

C9 = Missouri

D0 = Nebraska

D1 = New York

D2 = Ohio

D3 = Pennsylvania

D4 = South Carolina

D5 = Virginia

D6 = California

D7 = California

D8 = California

D9 = Arizona

E1 = Nevada

E2 = Texas

E3 = Texas

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The following blocks of numbers are reserved for the facilities indicated

(NOTE: may have different meanings dependent on the type of bill [TOB]):

0001–0879: Short-term (general and

specialty) hospitals where TOB = 11X;

ESRD clinic where TOB = 72X

0880–0899: Reserved for hospitals

participating in ORD demonstration

projects where TOB = 11X; ESRD clinic

where TOB = 72X

0900–0999: Multiple hospital

component in a medical complex

(numbers retired) where TOB = 11X;

ESRD clinic where TOB = 72X

1000–1199: Reserved for future use

1200–1224: Alcohol/drug hospitals

(excluded from PPS-numbers retired)

where TOB = 11X; ESRD clinic where

TOB = 72X

1225–1299: Medical assistance

facilities (Montana project); ESRD

clinic where TOB = 72X

1300–1399: Critical Access Hospitals

(CAH)

1400–1499: Continuation of 4900–

4999 series (CMHC)

1500–1799: Hospices

1800–1989: Federally Qualified Health

Centers (FQHC) where TOB = 73X; SNF

(IP PTB) where TOB = 22X; HHA where

TOB = 32X, 33X, 34X

1990–1999: Religious Nonmedical

Health Care Institutions (RNHCI)

2000–2299: Long-term hospitals

2300–2499: Chronic renal disease

facilities (hospital based)

2500–2899: Non-hospital renal disease

treatment centers

2900–2999: Independent special

purpose renal dialysis facility (1)

3000–3024: Formerly tuberculosis

hospitals (numbers retired)

3025–3099: Rehabilitation hospitals

3100–3199: Continuation of Subunits

of Nonprofit and Proprietary home

health Agencies (7300-7399) Series (3)

3200–3299: Continuation of 4800-

4899 series (CORF)

3300–3399: Children’s hospitals

(excluded from PPS) where TOB = 11X;

ESRD clinic where TOB = 72X

3400–3499: Continuation of rural

health clinics (provider-based) (3975-

3999)

3500–3699: Renal disease treatment

centers (hospital satellites)

3700–3799: Hospital based special

purpose renal dialysis facility (1)

3800–3974: Rural health clinics (free-

standing)

3975–3999: Rural health clinics (provider-

based)

4000–4499: Psychiatric hospitals

4500–4599: Comprehensive outpatient

Rehabilitation Facilities (CORF)

4600–4799: Community Mental Health

Centers (CMHC)

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4800–4899: Continuation of 4500–

4599 series (CORF)

4900–4999: Continuation of 4600–

4799 series (CMHC)

5000–6499: Skilled Nursing Facilities

6500–6989: CMHC/outpatient

physical therapy services where TOB

= 74X; CORF where TOB = 75X

6990–6999: Numbers Reserved

(formerly Christian Science)

7000–7299: Home health Agencies

(HHA) (2)

7300–7399: Subunits of “nonprofit”

and “proprietary” Home health

Agencies (3)

7400–7799: Continuation of 7000–

7299 series

7800–7999: Subunits of state and local

governmental home health agencies

(3)

8000–8499: Continuation of 7400–

7799 series (HHA)

8500–8899: Continuation of rural

health center (provider based) (3400–

3499)

8900–8999: Continuation of rural

health center (free-standing) (3800–

3974)

9000–9799: Continuation of 8000–

8499 series (HHA)

9800–9899: Transplant Centers (eff.

10/1/2007)

9900-9999: Freestanding Opioid

Treatment Program (eff. 1/2021)

NOTE: There is a special numbering system for units of hospitals that are excluded from prospective

payment system (PPS) and hospitals with SNF swing-bed designation. An alpha character in the third

position of the provider number identifies the type of unit or swing-bed designation as follows:

M = Psychiatric Unit in Critical Access

Hospital

R = Rehabilitation Unit in Critical

Access Hospital

S = Psychiatric unit (excluded from

PPS)

T = Rehabilitation unit (excluded from

PPS)

U = Swing-Bed Hospital Designation for

short-term hospitals

V = Alcohol drug unit (prior to 10/87

only)

W = Swing-Bed Hospital Designation for

long-term care hospitals

Y = Swing-Bed Hospital Designation for

Rehabilitation Hospitals

Z = Swing Bed Designation for Critical

Access Hospitals

There is also a special numbering system for assigning emergency hospital identification numbers

(non-participating hospitals).

The sixth position of the provider number is as follows:

E = Non-federal emergency hospital F = Federal emergency hospital

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COMMENT: Effective October 1, 2007, the OSCAR Provider Number has been renamed the CMS Certification

Number (CCN). The name was changed to avoid confusion with the National Provider Identifier (NPI).

The CCN will continue to play a critical role in verifying that a provider has been Medicare certified and

for what type of services.

Refer to CCW Technical Guidance document: “Getting Started with Medicare Data” for additional

information regarding service setting classifications.

If you want additional information about the institutional provider, the quarterly CMS Provider of

Services (POS) file contains dozens of variables that describe the characteristics of the provider. This

file is updated quarterly, and effective May 2014 is available for free online from the CMS website

(2005–current).

^ Back to TOC ^

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 320

PRVDR_NUM (DMERC claim)

LABEL: DMERC Line Supplier Provider Number

DESCRIPTION: The billing number assigned to the supplier of the Part B service/DMEPOS by the National Supplier

Clearinghouse, as reported on the line item for the DMERC claim.

SHORT NAME: SUPLRNUM

LONG NAME: PRVDR_NUM

TYPE: CHAR

LENGTH: 10

SOURCE: NCH

VALUES: —

COMMENT: Different types of identifiers may be used. Refer to the variable called DMERC_LINE_SUPPLR_TYPE_CD

to determine the type used for each line.

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 321

PRVDR_SPCLTY

LABEL: Line CMS Provider Specialty Code

DESCRIPTION: CMS (previously called HCFA) specialty code used for pricing the line-item service on the non-

institutional claim.

Assigned by the Medicare Administrative Contractor (MAC) based on the corresponding provider

identification number (performing NPI or UPIN).

SHORT NAME: HCFASPCL

LONG NAME: PRVDR_SPCLTY

TYPE: CHAR

LENGTH: 3

SOURCE: NCH

VALUES:

00 = Carrier wide

01 = General practice

02 = General surgery

03 = Allergy/immunology

04 = Otolaryngology

05 = Anesthesiology

06 = Cardiology

07 = Dermatology

08 = Family practice

09 = Interventional pain management

(IPM) (eff. 4/2003)

10 = Gastroenterology

11 = Internal medicine

12 = Osteopathic manipulative therapy

13 = Neurology

14 = Neurosurgery

15 = Speech/language pathology

16 = Obstetrics/gynecology

17 = Hospice and palliative care

18 = Ophthalmology

19 = Oral surgery (dentists only)

20 = Orthopedic surgery

21 = Cardiac electrophysiology

22 = Pathology

23 = Sports medicine

24 = Plastic and reconstructive surgery

25 = Physical medicine and

rehabilitation

26 = Psychiatry

27 = General psychiatry

28 = Colorectal surgery (formerly

proctology)

29 = Pulmonary disease

30 = Diagnostic radiology

31 = Intensive cardiac rehabilitation

32 = Anesthesiologist assistants (eff.

4/2003 — previously grouped

with Certified Registered Nurse

Anesthetists [CRNA])

33 = Thoracic surgery

34 = Urology

35 = Chiropractic

36 = Nuclear medicine

37 = Pediatric medicine

38 = Geriatric medicine

39 = Nephrology

40 = Hand surgery

41 = Optometrist

42 = Certified nurse midwife

43 = Certified Registered Nurse

Anesthetist (CRNA)

(Anesthesiologist assistants were

removed from this specialty

4/2003)

44 = Infectious disease

45 = Mammography screening center

46 = Endocrinology

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47 = Independent Diagnostic Testing

Facility (IDTF)

48 = Podiatry

49 = Ambulatory surgical center

(formerly miscellaneous)

50 = Nurse practitioner

51 = Medical supply company with

certified orthotist (certified by

American Board for Certification

in Prosthetics and Orthotics)

52 = Medical supply company with

certified prosthetist (certified by

American Board for Certification

in Prosthetics and Orthotics)

53 = Medical supply company with

certified prosthetist-orthotist

(certified by American Board for

Certification in Prosthetics and

Orthotics)

54 = Medical supply company for

DMERC (and not included in 51–

53)

55 = Individual certified orthotist

56 = Individual certified prosthetist

57 = Individual certified prosthetist-

orthotist

58 = Medical supply company with

registered pharmacist

59 = Ambulance service supplier, (e.g.,

private ambulance companies,

funeral homes, etc.)

60 = Public health or welfare agencies

(federal, state, and local)

61 = Voluntary health or charitable

agencies (e.g., National Cancer

Society, National Heart

Association, Catholic Charities)

62 = Psychologist (billing

independently)

63 = Portable X-ray supplier

64 = Audiologist (billing independently)

65 = Physical therapist (private

practice added 4/2003)

(independently practicing

removed 4/2003)

66 = Rheumatology

67 = Occupational therapist (private

practice added 4/2003)

(independently practicing removed

4/2003)

68 = Clinical psychologist

69 = Clinical laboratory (billing

independently)

70 = Single or multispecialty clinic or

group practice

71 = Registered Dietician/Nutrition

Professional (eff. 1/2002)

72 = Pain Management (eff. 1/2002)

73 = Mass Immunization Roster Biller

74 = Radiation Therapy Centers (prior to

4/2003 this included Independent

Diagnostic Testing Facilities (IDTF)

75 = Slide Preparation Facilities (added

to differentiate them from

Independent Diagnostic Testing

Facilities (IDTFs — eff. 4/2003)

76 = Peripheral vascular disease

77 = Vascular surgery

78 = Cardiac surgery

79 = Addiction medicine

80 = Licensed clinical social worker

81 = Critical care (intensivists)

82 = Hematology

83 = Hematology/oncology

84 = Preventive medicine

85 = Maxillofacial surgery

86 = Neuropsychiatry

87 = All other suppliers (e.g., drug and

department stores)

88 = Unknown supplier/provider

specialty

89 = Certified clinical nurse specialist

90 = Medical oncology

91 = Surgical oncology

92 = Radiation oncology

93 = Emergency medicine

94 = Interventional radiology

95 = Competitive Acquisition Program

(CAP) Vendor (eff. 07/2001/2006).

Prior to 07/2001/2006, known as

Independent physiological

laboratory

96 = Optician

97 = Physician assistant

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98 = Gynecologist/oncologist

99 = Unknown physician specialty

A0 = Hospital (DMERCs only)

A1 = SNF (DMERCs only)

A2 = Intermediate care nursing facility

(DMERCs only)

A3 = Nursing facility, other (DMERCs

only)

A4 = Home health agency (DMERCs

only)

A5 = Pharmacy (DMERC)

A6 = Medical supply company with

respiratory therapist (DMERCs

only)

A7 = Department store (DMERC)

A8 = Grocery store (DMERC)

A9 = Indian Health Service (his), tribe

and tribal organizations (non-

hospital or non-hospital-based

facilities, eff. 1/2005)

B1 = Supplier of oxygen and/or oxygen

related equipment (eff. 10/2007)

B2 = Pedorthic Personnel (eff.

10/2007)

B3 = Medical Supply Company with

pedorthic personnel (eff.

10/2007)

B4 = Does not meet definition of

health care provider (e.g.,

Rehabilitation agency, organ

procurement organizations,

histocompatibility labs) (eff.

10/2007)

B5 = Ocularist

C0 = Sleep medicine

C1 = Centralized flu

C2 = Indirect payment procedure

C3 = Interventional cardiology

C5 = Dentist

C6 = Hospitalist

C7 = Advanced Heart Failure and

Transplant Cardiology

C8 = Medical Toxicology

C9 = Hematopoietic Cell

Transplantation and Cellular

Therapy

D3 = Medical Genetics and Genomics

D4 = Undersea and Hyperbaric

Medicine

D5 = Opioid Treatment Program (eff.

1/2020)

D7 = Micrographic Dermatologic

Surgery

D8 = Adult Congenital Heart Disease

E1 = Marriage and Family Therapists

E2 = Mental Health Counselors

E3 = Dental Anesthesiology

E4 = Dental Public Health

E5 = Endodontics

E6 = Oral and Maxillofacial Pathology

E7 = Oral and Maxillofacial Radiology

E9 = Oral Medicine

F1 = Orofacial Pain

F2 = Orthodontics and Dentofacial

Orthopedics

F3 = Pediatric Dentistry

F4 = Periodontics

F5 = Prosthodontics

COMMENT: —

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 324

PRVDR_STATE_CD

LABEL: NCH Provider SSA State Code

DESCRIPTION: The two-digit numeric social security administration (SSA) state code where provider or facility is

located.

SHORT NAME: PRSTATE

LONG NAME: PRVDR_STATE_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES:

01 = Alabama

02 = Alaska

03 = Arizona

04 = Arkansas

05 = California

06 = Colorado

07 = Connecticut

08 = Delaware

09 = District of Columbia

10 = Florida

11 = Georgia

12 = Hawaii

13 = Idaho

14 = Illinois

15 = Indiana

16 = Iowa

17 = Kansas

18 = Kentucky

19 = Louisiana

20 = Maine

21 = Maryland

22 = Massachusetts

23 = Michigan

24 = Minnesota

25 = Mississippi

26 = Missouri

27 = Montana

28 = Nebraska

29 = Nevada

30 = New Hampshire

31 = New Jersey

32 = New Mexico

33 = New York

34 = North Carolina

35 = North Dakota

36 = Ohio

37 = Oklahoma

38 = Oregon

39 = Pennsylvania

40 = Puerto Rico

41 = Rhode Island

42 = South Carolina

43 = South Dakota

44 = Tennessee

45 = Texas

46 = Utah

47 = Vermont

48 = Virgin Islands

49 = Virginia

50 = Washington

51 = West Virginia

52 = Wisconsin

53 = Wyoming

54 = Africa

55 = Asia

56 = Canada

57 = Central America and West Indies

58 = Europe

59 = Mexico

60 = Oceania

61 = Philippines

62 = South America

63 = U.S. Possessions

64 = American Samoa

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65 = Guam

66 = Commonwealth of the Northern

Marianas Islands

97 = Northern Marianas

98 = Guam

99 = Unknown or if county code = 000

then this is American Samoa

COMMENT: As two-digit state codes used for the CMS Certification Number (CCN) (field called the PRVDR_NUM)

have been exhausted, CMS implemented a two-position alpha-numeric coding system for State Codes.

When this occurs, CMS mapped the alphanumeric codes to these SSA state codes. For example, even

though Florida CCNs include the first 2-digits (state codes) 10, 68, 69, and A2, all will have

PRVDR_STATE_CD = 10. NOTE: Effective July 26, 2024, the following CCN assigned state codes are

being added to the derivation rules for the provider state code (D6, D7, D8, D9, E1, E2, E3). If these

states codes were received prior to July 26, 2024, they are not mapped to the provider state.

^ Back to TOC ^

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PRVDR_VLDTN_TYPE_CD

LABEL: Provider Validation Type Code

DESCRIPTION: Provider Validation Type Code

SHORT NAME: PRVDR_VLDTN_TYPE_CD

LONG NAME: PRVDR_VLDTN_TYPE_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES: RP = Rendering Provider

OP = Operating Physician

CP = Ordering/Referring Physician

AP = Attending Physician

FA = Facility

COMMENT: The purpose of the Provider Validation Type field on the claim is to inform Common Working File

(CWF) to perform an edit check to ensure that the provider that was submitted on the Prior

Authorization (PA) request is the same provider on the claim.

This field was new in April 2019.

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PRVDR_ZIP

LABEL: Carrier Line Performing Provider ZIP Code

DESCRIPTION: The ZIP code of the physician/supplier who performed the Part B service for this line item on the

carrier claim (non-DMERC).

SHORT NAME: PROVZIP

LONG NAME: PRVDR_ZIP

TYPE: CHAR

LENGTH: 9

SOURCE: NCH

VALUES: —

COMMENT: —

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 328

PTNT_DSCHRG_STUS_CD

LABEL: Patient Discharge Status Code

DESCRIPTION: The code used to identify the status of the patient as of the CLM_THRU_DT.

SHORT NAME: STUS_CD

LONG NAME: PTNT_DSCHRG_STUS_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES:

0 = Unknown Value (but present in

data)

01 = Discharged to home/self-care

(routine charge)

02 = Discharged/transferred to other

short term general hospital for

inpatient care

03 = Discharged/transferred to skilled

nursing facility (SNF) with

Medicare certification in

anticipation of covered skilled

care — (For hospitals with an

approved swing bed arrangement,

use Code 61 — swing bed. For

reporting discharges/transfers to

a non-certified SNF, the hospital

must use Code 04 — ICF

04 = Discharged/transferred to

intermediate care facility (ICF)

05 = Discharged/transferred to

another type of institution for

inpatient care (including distinct

parts). NOTE: Effective 1/2005,

psychiatric hospital or psychiatric

distinct part unit of a hospital will

no longer be identified by this

code. New code is “65”

06 = Discharged/transferred to home care

of organized home health service

organization

07 = Left against medical advice or

discontinued care

08 = Discharged/transferred to home under

care of a home IV drug therapy

provider. (discontinued eff. 10/1/2005)

09 = Admitted as an inpatient to this

hospital (eff. 3/1/1991). In situations

where a patient is admitted before

midnight of the third day following the

day of an outpatient service, the

outpatient services are considered

inpatient

20 = Expired (patient did not recover)

21 = Discharged/transferred to court/law

enforcement

30 = Still patient

40 = Expired at home (hospice claims only)

41 = Expired in a medical facility such as

hospital, SNF, ICF, or freestanding

hospice. (hospice claims only)

42 = Expired — place unknown (hospice

claims only)

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43 = Discharged/transferred to a

federal hospital (eff. 10/1/2003)

50 = Discharged/transferred to a

hospice — home

51 = Discharged/transferred to a

hospice — medical facility

61 = Discharged/transferred within this

institution to a hospital-based

Medicare approved swing bed

(eff. 9/2001)

62 = Discharged/transferred to an

inpatient rehabilitation facility

including distinct parts units of a

hospital. (eff. 1/2002)

63 = Discharged/transferred to a long-

term care hospital. (eff. 1/2002)

64 = Discharged/transferred to a

nursing facility certified under

Medicaid but not under Medicare

(eff. 10/2002)

65 = Discharged/Transferred to a psychiatric

hospital or psychiatric distinct unit of a hospital

(these types of hospitals were pulled from

patient/discharge status code “05” and given

their own code). (eff. 1/2005)

66 = Discharged/transferred to a Critical

Access Hospital (CAH) (eff. 1/1/2006)

69 = Discharged/transferred to a designated

disaster alternative care site (starting

10/2013; applies only to particular MS-

DRGs*)

70 = Discharged/transferred to

another type of health care

institution not defined elsewhere

in code list

71 = Discharged/transferred/referred

to another institution for

outpatient services as specified

by the discharge plan of care (eff.

9/2001) (discontinued eff.

10/1/2005)

72 = Discharged/transferred/referred

to this institution for outpatient

services as specified by the

discharge plan of care (eff.

9/2001) (discontinued eff.

10/1/2005)

The following codes apply only to particular MS-DRGs*, and were new in 10/2013:

81 = Discharged to home or self-care

with a planned acute care

hospital inpatient readmission

82 = Discharged/transferred to a

short-term general hospital for

inpatient care with a planned

acute care hospital inpatient

readmission

83 = Discharged/transferred to a

skilled nursing facility (SNF) with

Medicare certification with a

planned acute care hospital

inpatient readmission

84 = Discharged/transferred to a

facility that provides custodial or

supportive care with a planned

acute care hospital inpatient

readmission

85 = Discharged/transferred to a

designated cancer center or

children’s hospital with a planned

acute care hospital inpatient

readmission

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86 = Discharged/transferred to home

under care of organized home

health service organization with

a planned acute care hospital

inpatient readmission

87 = Discharged/transferred to

court/law enforcement with a

planned acute care hospital

inpatient readmission

88 = Discharged/transferred to a

federal health care facility with a

planned acute care hospital

inpatient readmission

89 = Discharged/transferred to a

hospital-based Medicare

approved swing bed with a

planned acute care hospital

inpatient readmission

90 = Discharged/transferred to an

inpatient rehabilitation facility

(IRF) including rehabilitation

distinct part units of a hospital

with a planned acute care hospital

inpatient readmission

91 = Discharged/transferred to a Medicare

certified long-term care hospital

(LTCH) with a planned acute care

hospital inpatient readmission

92 = Discharged/transferred to a

nursing facility certified under

Medicaid but not certified under

Medicare with a planned acute

care hospital inpatient readmission

93 = Discharged/transferred to a

psychiatric distinct part unit of a

hospital with a planned acute care

hospital inpatient readmission

94 = Discharged/transferred to a critical

access hospital (CAH) with a

planned acute care hospital

inpatient readmission

95 = Discharged/transferred to another

type of health care institution not

defined elsewhere in this code list

with a planned acute care hospital

inpatient readmission

COMMENT: * MS-DRG codes where additional codes were available in October 2013 are:

• 280 (Acute Myocardial Infarction, Discharged Alive with MCC),

• 281 (Acute Myocardial Infarction, Discharged Alive with CC),

• 282 (Acute Myocardial Infarction, Discharged Alive without CC/MCC), and

• 789 (Neonates, Died or Transferred to Another Acute Care Facility).

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RC_MODEL_REIMBRSMT_AMT

LABEL: Revenue Center Model Reimbursement Amount

DESCRIPTION: This field is used to identify the “net reimbursement amount” of what Medicare would have paid for

the global budget service reflected at the line level, from a hospital participating in the particular

model.

SHORT NAME: RC_PTNT_ADD_ON_PYMT_AMT

LONG NAME: RC_PTNT_ADD_ON_PYMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

COMMENT: This field is new in January 2020. This field only applies to Part A claims.

For participating hospitals within the PA model all inpatient and outpatient services (facility/technical

services) are considered a part of the model/global budget services. Basically, all the services for

participating hospitals would be global except for CAH Method II (where the bill type is 85X) claims

lines with revenue codes 096x, 097x, or 098x. The CAH Method II professional services (REV codes

096x, 097x, or 098x) process as they do today, they have nothing to do with the model.

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RC_PTNT_ADD_ON_PYMT_AMT

LABEL: Revenue Center Patient/Initial Visit Add-On Payment Amount (for initial wellness visit)

DESCRIPTION: This field is the revenue-center Patient Initial Visit Add-On Amount. This field represents a base rate

increase factor of 1.3516 for new patient initial preventive physical examination (IPPE) and annual

wellness visit.

SHORT NAME: RC_PTNT_ADD_ON_PYMT_AMT

LONG NAME: RC_PTNT_ADD_ON_PYMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: This field is new in October 2014.This field only applies to outpatient claims.

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RC_VLNTRY_SRVC_IND_CD

LABEL: Revenue Center Voluntary Service Indicator Code

DESCRIPTION: Effective with version “L” of the NCH layout, this line level field will be used to identify if the service

(procedure code) was voluntary or required.

SHORT NAME: RC_VLNTRY_SRVC_IND_CD

LONG NAME: RC_VLNTRY_SRVC_IND_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: V = A voluntary procedure code

Null/missing = A required procedure code

COMMENT: This field was new in January 2021.

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REV_CNTR

LABEL: Revenue Center Code

DESCRIPTION: The provider-assigned revenue code for each cost center for which a separate charge is billed (type of

accommodation or ancillary). A cost center is a division or unit within a hospital (e.g., radiology,

emergency room, pathology).

EXCEPTION: Revenue center code 0001 represents the total of all revenue centers included on the

claim.

SHORT NAME: REV_CNTR

LONG NAME: REV_CNTR

TYPE: CHAR

LENGTH: 4

SOURCE: NCH

VALUES: This code set is an external code set maintained by the National Uniform Billing Committee (NUBC™)

https://www.nubc.org/

The values listed below may not be complete or current

0001 = Total charge

0022 = SNF claim paid under PPS

submitted as type of bill (TOB)

21X

NOTE: This code may appear multiple

times on a claim to identify different

HIPPS Rate Code/assessment periods.

0023 = Home health services paid

under PPS submitted as TOB 32X

and 33X, eff. 10/2000. This code

may appear multiple times on a

claim to identify different

HIPPS/home health Resource

Groups (HRG)

0024 = Inpatient rehabilitation facility

services paid under PPS

submitted as TOB 11X, eff. for

cost reporting periods beginning

on or after 1/1/2002 (dates of

service after 12/31/2001). This

code may appear only once on a

claim

0100 = All-inclusive rate — room and board plus

ancillary

0101 = All-inclusive rate — room and board

0110 = Private medical or general — general

classification

0111 = Private medical or general —

medical/surgical/GYN

0112 = Private medical or general — OB

0113 = Private medical or general — pediatric

0114 = Private medical or general — psychiatric

0115 = Private medical or general — hospice

0116 = Private medical or general — detoxification

0117 = Private medical or general — oncology

0118 = Private medical or general — rehabilitation

0119 = Private medical or general — other

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0120 = Semi-private 2 bed (medical or

general) general classification

0121 = Semi-private 2 bed (medical or

general) medical/surgical/GYN

0122 = Semi-private 2 bed (medical or

general) — OB

0123 = Semi-private 2 bed (medical or

general) — pediatric

0124 = Semi-private 2 bed (medical or

general) — psychiatric

0125 = Semi-private 2 bed (medical or

general) — hospice

0126 = Semi-private 2 bed (medical or

general) — detoxification

0127 = Semi-private 2 bed (medical or

general) — oncology

0128 = Semi-private 2 bed (medical or

general) — rehabilitation

0129 = Semi-private 2 bed (medical or

general) — other

0130 = Semi-private 3 and 4 beds —

general classification

0131 = Semi-private 3 and 4 beds —

medical/surgical/GYN

0132 = Semi-private 3 and 4 beds —

0133 = Semi-private 3 and 4 beds —

pediatric

0134 = Semi-private 3 and 4 beds —

psychiatric

0135 = Semi-private 3 and 4 beds

— hospice

0136 = Semi-private 3 and 4 beds —

detoxification

0137 = Semi-private 3 and 4 beds —

oncology

0138 = Semi-private 3 and 4 beds —

rehabilitation

0139 = Semi-private 3 and 4 beds — other

0140 = Private (deluxe)-general classification

0141 = Private (deluxe) —

medical/surgical/GYN

0142 = Private (deluxe) — OB

0143 = Private (deluxe) — pediatric

0144 = Private (deluxe) — psychiatric

0145 = Private (deluxe) — hospice

0146 = Private (deluxe) — detoxification

0147 = Private (deluxe) — oncology

0148 = Private (deluxe) — rehabilitation

0149 = Private (deluxe) — other

0150 = Room and Board ward (medical or

general) — general classification

0151 = Room and Board ward (medical or

general) — medical/surgical/GYN

0152 = Room and Board ward (medical or

general) — OB

0153 = Room and Board ward (medical or

general) — pediatric

0154 = Room and Board ward (medical or

general) — psychiatric

0155 = Room and Board ward (medical or

general) — hospice

0156 = Room and Board ward (medical or

general) — detoxification

0157 = Room and Board ward (medical or

general) — oncology

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0158 = Room and Board ward (medical

or general) — rehabilitation

0159 = Room and Board ward (medical

or general) — other

0160 = Other Room and Board —

general classification

0161 = Hospital at home,

RandB/hospital at home (eff. for

claims received on or after July

1, 2022)

0164 = Other Room and Board —

sterile environment

0167 = Other Room and Board — self

care

0169 = Other Room and Board — other

0170 = Nursery-general classification

0171 = Nursery — newborn level I

(routine)

0172 = Nursery — premature

newborn-level II (continuing

care)

0173 = Nursery — newborn-level III

(intermediate care)

0174 = Nursery — newborn-level IV

(intensive care)

0179 = Nursery — other

0180 = Leave of absence — general

classification

0182 = Leave of absence — patient

convenience charges billable

0183 = Leave of absence —

therapeutic leave

0184 = Leave of absence-ICF mentally

retarded — any reason

0185 = Leave of absence nursing home

(hospitalization)

0189 = Leave of absence — other leave

of absence

0190 = Subacute care — general

classification

0191 = Subacute care — level I

0192 = Subacute care — level II

0193 = Subacute care — level III

0194 = Subacute care — level IV

0199 = Subacute care — other

0200 = Intensive care — general

classification

0201 = Intensive care — surgical

0202 = Intensive care — medical

0203 = Intensive care — pediatric

0204 = Intensive care — psychiatric

0206 = Intensive care—post ICU;

redefined as intermediate ICU

0207 = Intensive care — burn care

0208 = Intensive care — trauma

0209 = Intensive care — other intensive

care

0210 = Coronary care — general

classification

0211 = Coronary care — myocardial

infraction

0212 = Coronary care — pulmonary care

0213 = Coronary care — heart transplant

0214 = Coronary care — post CCU;

redefined as intermediate CCU

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0219 = Coronary care — other

coronary care

0220 = Special charges — general

classification

0221 = Special charges — admission

charge

0222 = Special charges — technical

support charge

0223 = Special charges — UR service

charge

0224 = Special charges — late

discharge, medically necessary

0229 = Special charges — other special

charges

0230 = Incremental nursing charge

rate — general classification

0231 = Incremental nursing charge

rate — nursery

0232 = Incremental nursing charge

rate — OB

0233 = Incremental nursing charge

rate — ICU (include transitional

care)

0234 = Incremental nursing charge

rate — CCU (include transitional

care)

0235 = Incremental nursing charge

rate — hospice

0239 = Incremental nursing charge

rate — other

0240 = All-inclusive ancillary —

general classification

0241 = All-inclusive ancillary — basic

0242 = All-inclusive ancillary —

comprehensive

0243 = All-inclusive ancillary — specialty

0249 = All-inclusive ancillary — other inclusive

ancillary

0250 = Pharmacy — general classification

0251 = Pharmacy — generic drugs

0252 = Pharmacy — nongeneric drugs

0253 = Pharmacy — take home drugs

0254 = Pharmacy — drugs incident to

other diagnostic service-subject

payment limit

0255 = Pharmacy — drugs incident to

radiology-subject to payment

limit

0256 = Pharmacy — experimental

drugs

0257 = Pharmacy — non-prescription

0258 = Pharmacy — IV solutions

0259 = Pharmacy — other pharmacy

0260 = IV therapy — general

classification

0261 = IV therapy — infusion pump

0262 = IV therapy — pharmacy services

0263 = IV therapy — drug

supply/delivery

0264 = IV therapy — supplies

0269 = IV therapy — other IV therapy

0270 = Medical/surgical supplies — general

classification (also reference 062X)

0271 = Medical/surgical supplies —

nonsterile supply

0272 = Medical/surgical supplies — sterile

supply

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0273 = Medical/surgical supplies —

take home supplies

0274 = Medical/surgical supplies —

prosthetic/orthotic devices

0275 = Medical/surgical supplies —

pacemaker

0276 = Medical/surgical supplies —

intraocular lens

0277 = Medical/surgical supplies —

oxygen-take home

0278 = Medical/surgical supplies —

other implants

0279 = Medical/surgical supplies —

other devices

0280 = Oncology — general

classification

0289 = Oncology — other oncology

0290 = DME (other than renal) —

general classification

0291 = DME (other than renal) —

rental

0292 = DME (other than renal) —

purchase of new DME

0293 = DME (other than renal) —

purchase of used DME

0294 = DME (other than renal) —

related to and listed as DME

0299 = DME (other than renal) —

other

0300 = Laboratory — general

classification

0301 = Laboratory — chemistry

0302 = Laboratory — immunology

0303 = Laboratory — renal patient

(home)

0304 = Laboratory — non-routine

dialysis

0305 = Laboratory — hematology

0306 = Laboratory — bacteriology and

microbiology

0307 = Laboratory — urology

0308 = Reserved laboratory

0309 = Laboratory — other laboratory

0310 = Laboratory pathological —

general classification

0311 = Laboratory pathological — cytology

0312 = Laboratory pathological — histology

0314 = Laboratory pathological — biopsy

0319 = Laboratory pathological — other

0320 = Radiology diagnostic — general

classification

0321 = Radiology diagnostic —

angiocardiography

0322 = Radiology diagnostic — arthrography

0323 = Radiology diagnostic — arteriography

0324 = Radiology diagnostic — chest X-ray

0327 = Reserved radiology, diagnostic

0329 = Radiology diagnostic — other

0330 = Radiology therapeutic — general

classification

0331 = Radiology therapeutic —

chemotherapy injected

0332 = Radiology therapeutic —

chemotherapy oral

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0333 = Radiology therapeutic —

radiation therapy

0335 = Radiology therapeutic —

chemotherapy IV

0339 = Radiology therapeutic — other

0340 = Nuclear medicine — general

classification

0341 = Nuclear medicine — diagnostic

0342 = Nuclear medicine —

therapeutic

0343 = Nuclear medicine — diagnostic

radiopharmaceuticals

0344 = Nuclear medicine —

therapeutic

radiopharmaceuticals

0349 = Nuclear medicine — other

0350 = Computed tomographic (CT)

scan — general classification

0351 = CT scan — head scan

0352 = CT scan — body scan

0359 = CT scan — other CT scans

0360 = Operating room services —

general classification

0361 = Operating room services —

minor surgery

0362 = Operating room services —

organ transplant, other than

kidney

0363 = Reserved operating room

services

0367 = Operating room services —

kidney transplant

0368 = Reserved operating room services

0369 = Operating room services — other

operating room services

0370 = Anesthesia — general

classification

0371 = Anesthesia — incident to RAD and

subject to the payment limit

0372 = Anesthesia — incident to other

diagnostic service and subject to

the payment limit

0374 = Anesthesia — acupuncture

0379 = Anesthesia — other anesthesia

0380 = Blood — general classification

0381 = Blood — packed red cells

0382 = Blood — whole blood

0383 = Blood — plasma

0384 = Blood — platelets

0385 = Blood — leukocytes

0386 = Blood — other components

0387 = Blood — other derivatives

(cryoprecipitates)

0389 = Blood — other blood

0390 = Blood storage and processing —

general classification

0391 = Blood storage and processing —

blood administration

0392 = Blood storage and processing —

storage and processing

0399 = Blood storage and processing —

other

0400 = Other imaging services — general

classification

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0401 = Other imaging services —

diagnostic mammography

0402 = Other imaging services —

ultrasound

0403 = Other imaging services —

screening mammography

0404 = Other imaging services —

positron emission tomography

0405 = Reserved imaging services

0409 = Other imaging services — other

0410 = Respiratory services — general

classification

0412 = Respiratory services —

inhalation services

0413 = Respiratory services —

hyperbaric oxygen therapy

0419 = Respiratory services — other

0420 = Physical therapy — general

classification

0421 = Physical therapy — visit charge

0422 = Physical therapy — hourly

charge

0423 = Physical therapy — group rate

0424 = Physical therapy — evaluation

or re-evaluation

0429 = Physical therapy — other

0430 = Occupational therapy —

general classification

0431 = Occupational therapy — visit

charge

0432 = Occupational therapy —

hourly charge

0433 = Occupational therapy —

group rate

0434 = Occupational therapy —

evaluation or re-evaluation

0439 = Occupational therapy — other

(may include restorative therapy)

0440 = Speech language pathology —

general classification

0441 = Speech language pathology —

visit charge

0442 = Speech language pathology —

hourly charge

0443 = Speech language pathology —

group rate

0444 = Speech language pathology —

evaluation or re-evaluation

0445 = Reserved speech therapy

0449 = Speech language pathology —

other

0450 = Emergency room — general

classification

0451 = Emergency room — EMTALA

emergency medical screening

services

0452 = Emergency room — ER beyond

EMTALA screening

0456 = Emergency room — urgent care

0459 = Emergency room — other

0460 = Pulmonary function — general

classification

0461 = Reserved pulmonary function

0469 = Pulmonary function — other

0470 = Audiology — general classification

0471 = Audiology — diagnostic

0472 = Audiology — treatment

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0479 = Audiology — other

0480 = Cardiology — general

classification

0481 = Cardiology — cardiac cath lab

0482 = Cardiology — stress test

0483 = Cardiology — Echocardiology

0489 = Cardiology — other

0490 = Ambulatory surgical care —

general classification

0499 = Ambulatory surgical care —

other

0500 = Outpatient services — general

classification

0509 = Outpatient services — other

0510 = Clinic — general classification

0511 = Clinic — chronic pain center

0512 = Clinic — dental center

0513 = Clinic — psychiatric

0514 = Clinic — OB-GYN

0515 = Clinic — pediatric

0516 = Clinic — urgent care clinic

0517 = Clinic — family practice clinic

0519 = Clinic — other

0520 = Free-standing clinic —

general classification

0521 = Free-standing clinic — clinic

visit by a member to

RHC/FQHC (eff. 7/1/2006).

Prior to 7/1/2006 — rural

health clinic

0522 = Free-standing clinic — home visit by

RHC/FQHC practitioner (eff. 7/2006).

Prior to 7/2006 — rural health home

0523 = Free-standing clinic — family

practice

0524 = Free-standing clinic — visit by

RHC/FQHC practitioner to a member

in a covered Part A stay at the SNF.

(eff. 7/2006)

0525 = Free-standing clinic — visit by

RHC/FQHC practitioner to a member

in a SNF (not in a covered Part A stay)

or NF or ICF MR or other residential

facility. (eff. 7/2006)

0526 = Free-standing clinic — urgent care

(eff. 10/1996)

0527 = Free-standing clinic — RHC/FQHC

visiting nurse service(s) to a member's

home when in a home health shortage

area. (eff. 7/2006)

0528 = Free-standing clinic — visit by

RHC/FQHC practitioner to other non-

RHC/FQHC site (e.g., scene of

accident). (eff. 7/2006)

0529 = Free-standing clinic — other

0530 = Osteopathic services — general

classification

0531 = Osteopathic services — osteopathic

therapy

0539 = Osteopathic services — other

0540 = Ambulance — general classification

0541 = Ambulance — supplies

0542 = Ambulance — medical transport

0543 = Ambulance — heart mobile

0544 = Ambulance — oxygen

0545 = Ambulance — air ambulance

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0546 = Ambulance — neo-natal

ambulance

0547 = Ambulance — pharmacy

0548 = Ambulance —transmission EKG

0549 = Ambulance — other

0550 = Skilled nursing — general

classification

0551 = Skilled nursing — visit charge

0552 = Skilled nursing — hourly charge

0559 = Skilled nursing — other

0560 = Medical social services (home

health) — general classification

0561 = Medical social services (home

health) — visit charge

0562 = Medical social services (home

health) — hourly charges

0569 = Medical social services (home

health) — other

0570 = Home health aide (home

health) — general

classification

0571 = Home health aide (home

health) — visit charge

0572 = Home health aide (home

health) — hourly charge

0579 = Home health aide (home

health) — other

0580 = Other visits (home health) —

general classification (under

HHPPS, not allowed as

covered charges)

0581 = Other visits (home health) —

visit charge (under HHPPS,

not allowed as covered

charges)

0582 = Other visits (home health) —

hourly charge (under HHPPS, not

allowed as covered charges)

0583 = Other visits (home health) —

assessments under HHPPS, not

allow as covered charges)

0589 = Other visits (home health) —

other (under HHPPS, not allowed

as covered charges)

0590 = Units of service (home health) —

general classification (under

HHPPS, not allowed as covered

charges)

0599 = Units of service (home health) —

other (under HHPPS, not allowed

as covered charges)

0600 = Oxygen (home health) — general

classification

0601 = Oxygen (home health) — stat or

port equip/supply or contents

0602 = Oxygen (home health)—

stat/equip/supply under 1 LPM

0603 = Oxygen (home health) —

stat/equip/over 4 LPM

0604 = Oxygen (home health) —

stat/equip/portable add-on

0609 = Oxygen (home health) — other

0610 = Magnetic resonance technology

(MRT) — general classification

0611 = MRT/MRI — brain (including

brainstem)

0612 = MRT/MRI — spinal cord (including

spine)

0614 = MRT/MRI — other

0615 = MRT/MRA — Head and Neck

0616 = MRT/MRA — Lower Extremities

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0618 = MRT/MRA — other

0619 = MRT/Other MRI

0620 = Reserved (Use 0270 for general

classification)

0621 = Medical/surgical supplies —

incident to radiology-subject to

the payment limit — extension

of 027X

0622 = Medical/surgical supplies —

incident to other diagnostic

service-subject to the payment

limit — extension of 027X

0623 = Medical/surgical supplies —

surgical dressings — extension

of 027X

0624 = Medical/surgical supplies —

medical investigational devices

and procedures with FDA

approved IDE's — extension of

027X

0630 = Reserved

0631 = Drugs requiring specific

identification — single drug

source

0632 = Drugs requiring specific

identification — multiple drug

source

0633 = Drugs requiring specific

identification — restrictive

prescription

0634 = Drugs requiring specific

identification — Erythropoietin

(EPO) under 10,000 units

0635 = Drugs requiring specific

identification — Erythropoietin

(EPO) 10,000 units or more

0636 = Drugs requiring specific

identification — detailed coding

0637 = Self-administered drugs administered

in an emergency situation — not

requiring detailed coding

0640 = Home IV therapy — general

classification

0641 = Home IV therapy — nonroutine

nursing

0642 = Home IV therapy — IV site care,

central line

0643 = Home IV therapy — IV start/change

peripheral line

0644 = Home IV therapy — nonroutine

nursing, peripheral line

0645 = Home IV therapy — train

patient/caregiver, central line

0646 = Home IV therapy — train disabled

patient, central line

0647 = Home IV therapy — train

patient/caregiver, peripheral line

0648 = Home IV therapy — train disabled

patient, peripheral line

0649 = Home IV therapy — other IV therapy

services

0650 = Hospice services — general

classification

0651 = Hospice services — routine home

care

0652 = Hospice services — continuous home

care-

0655 = Hospice services — inpatient care

0656 = Hospice services — general

inpatient care (non-respite)

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0657 = Hospice services — physician

services

0659 = Hospice services — other

0660 = Respite care (HHA) — general

classification

0661 = Respite care (HHA) — hourly

charge/skilled nursing

0662 = Respite care (HHA) — hourly

charge/home health

aide/homemaker

0663 = Respite care (HHA) - daily

respite charge

0670 = OP special residence charges —

general classification

0671 = OP special residence charges —

hospital based

0672 = OP special residence charges —

contracted

0679 = OP special residence charges —

other special residence charges

0680 = Trauma Response — not used

0681 = Trauma response — Level I

Trauma

0682 = Trauma response — Level II

Trauma

0683 = Trauma response — Level III

Trauma

0684 = Trauma response — Level IV

Trauma

0689 = Trauma response — Other

trauma response

0690 = Pre-hospice/Palliative Care

Services — general (eff.

7/2017)

0691 = Pre-hospice/Palliative Care Services

— visit (eff. 7/2017)

0692 = Pre-hospice/Palliative Care Services

— hourly (eff. 7/2017)

0693 = Pre-hospice/Palliative Care

Services — evaluation (eff. 7/2017)

0694 = Pre-hospice/Palliative Care

Services — consultation and

education (eff. 7/2017)

0695 = Pre-hospice/Palliative Care

Services — Inpatient (eff. 7/2017)

0696 = Pre-hospice/Palliative Care

Services — Physician (eff. 7/2017)

0699 = Pre-hospice/Palliative Care

Services — Other (eff. 7/2017)

0700 = Cast room — general classification

0709 = Cast room — other

0710 = Recovery room — general

classification

0719 = Recovery room — other

0720 = Labor room/delivery — general

classification

0721 = Labor room/delivery — labor

0722 = Labor room/delivery — delivery

0723 = Labor room/delivery —

circumcision

0724 = Labor room/delivery — birthing

center

0729 = Labor room/delivery — other

0730 = EKG/ECG Electrocardiogram —

general classification

0731 = EKG/ECG — Holter monitor

0732 = EKG/ECG — telemetry

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0739 = EKG/ECG — other

0740 = EEG Electroencephalogram —

general classification

0743 = Reserved

electroencephalogram (EEG)

0749 = EEG (electroencephalogram) —

other

0750 = Gastro-intestinal services —

general classification

0751 = Reserved gastrointestinal (GI)

services

0759 = Gastro-intestinal services —

other

0760 = Treatment or observation room

— general classification

0761 = Treatment or observation room

— treatment room

0762 = Treatment or observation room

— observation room

0769 = Treatment or observation room

— other

0770 = Preventive care services —

general classification

0771 = Preventive care services —

vaccine administration

0779 = Preventive care services —

other

0780 = Telemedicine — general

classification

0789 = Telemedicine — telemedicine

0790 = Extra-Corporeal Shock Wave

Therapy (formerly Lithotripsy)

— general classification

0799 = Extra-Corporeal Shock Wave

Therapy (formerly Lithotripsy) —

other

0800 = Inpatient renal dialysis —

general classification

0801 = Inpatient renal dialysis — inpatient

hemodialysis

0802 = Inpatient renal dialysis — inpatient

peritoneal (non-CAPD)

0803 = Inpatient renal dialysis — inpatient

Continuous Ambulatory Peritoneal

Dialysis (CAPD)

0804 = Inpatient renal dialysis — inpatient

Continuous Cycling Peritoneal Dialysis

(CCPD)

0809 = Inpatient renal dialysis — other

inpatient dialysis

0810 = Organ acquisition — general

classification

0811 = Organ acquisition — living donor

0812 = Organ acquisition — cadaver donor

0813 = Organ acquisition — unknown donor

0814 = Organ acquisition — unsuccessful

organ search-donor bank charges

0815 = Allogeneic Stem Cell

Acquisition/Donor Services

0819 = Organ acquisition — other donor

0820 = Hemodialysis OP or home dialysis —

general classification

0821 = Hemodialysis OP or home dialysis

— hemodialysis-composite or other

rate

0822 = Hemodialysis OP or home dialysis

— home supplies

Chronic Conditions Warehouse Virtual Research Data Center

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0823 = Hemodialysis OP or home

dialysis — home equipment

0824 = Hemodialysis OP or home

dialysis — maintenance/100%

0825 = Hemodialysis OP or home

dialysis — support services

0829 = Hemodialysis OP or home

dialysis — other

0830 = Peritoneal dialysis OP or home

— general classification

0831 = Peritoneal dialysis OP or home

— peritoneal-composite or

other rate

0832 = Peritoneal dialysis OP or home

— home supplies

0833 = Peritoneal dialysis OP or home

— home equipment

0834 = Peritoneal dialysis OP or home

— maintenance/100%

0835 = Peritoneal dialysis OP or home

— support services

0839 = Peritoneal dialysis OP or home

— other

0840 = Continuous Ambulatory

Peritoneal Dialysis (CAPD)

outpatient — general

classification

0841 = Continuous Ambulatory

Peritoneal Dialysis (CAPD)

outpatient — CAPD/composite

or other rate

0842 = Continuous Ambulatory

Peritoneal Dialysis (CAPD)

outpatient — home supplies

0843 = Continuous Ambulatory

Peritoneal Dialysis (CAPD)

outpatient — home equipment

0844 = Continuous Ambulatory Peritoneal

Dialysis (CAPD) outpatient —

maintenance/100%

0845 = Continuous Ambulatory Peritoneal

Dialysis (CAPD) outpatient — support

services

0849 = Continuous Ambulatory Peritoneal

Dialysis (CAPD) outpatient — other

0850 = Continuous Cycling Peritoneal Dialysis

(CCPD) outpatient — general

classification

0851 = Continuous Cycling Peritoneal Dialysis

(CCPD) outpatient — CCPD/composite

or other rate

0852 = Continuous Cycling Peritoneal Dialysis

(CCPD) outpatient — home supplies

0853 = Continuous Cycling Peritoneal Dialysis

(CCPD) outpatient — home

equipment

0854 = Continuous Cycling Peritoneal Dialysis

(CCPD) outpatient —

maintenance/100%

0855 = Continuous Cycling Peritoneal Dialysis

(CCPD) outpatient — support services

0859 = Continuous Cycling Peritoneal Dialysis

(CCPD) outpatient — other

0860 = Magnetoencephalography (MEG) —

general classification

0861 = Magnetoencephalography (MEG) —

MEG

0870 = Cell/Gene Therapy — General

0871 = Cell/Gene Therapy — Cell Collection

0872 = Cell/Gene Therapy — Specialized

Biologic Processing and Storage —

Prior To Transport

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0873 = Cell/Gene Therapy — Storage

and Processing After Receipt

of Cells from Manufacturer

0874 = Cell/Gene Therapy — Infusion

of Modified Cells (eff. 4/2019)

0875 = Cell/Gene Therapy — Injection

of Modified Cells (eff. 4/2019)

0880 = Miscellaneous dialysis —

general classification

0881 = Miscellaneous dialysis —

ultrafiltration

0882 = Miscellaneous dialysis — home

dialysis aide visit

0889 = Miscellaneous dialysis — other

0890 = Other donor bank — general

classification; changed to

reserved for national assignment

0891 = Special Processed Drugs - FDA

Approved Cell Therapy (eff.

4/2019);Other donor bank —

bone (retired 4/2019)

0892 = Special Processed Drugs — FDA

Approved Gene Therapy (eff.

4/2020); Other donor bank-

organ (other than kidney);

changed to reserved for national

assignment (terminated 3/2020)

0893 = Other donor bank — skin;

changed to reserved for national

assignment

0899 = Other donor bank — other;

changed to reserved for national

assignment

0900 = Behavior Health Treatment/

Services — general classification

(eff. 10/2004); prior to 10/2004

defined as Psychiatric/

psychological treatments —

general classification

0901 = Behavior Health Treatment/

Services — electroshock treatment

(eff. 10/2004); prior to 10/2004

defined as Psychiatric/psychological

treatments — electroshock

treatment

0902 = Behavior Health Treatment/

Services — milieu therapy (eff.

10/2004); prior to 10/2004 defined

as Psychiatric/psychological

treatments — milieu therapy

0903 = Behavior Health Treatment/Services

— play therapy (eff. 10/2004); prior

to 10/2004 defined as

Psychiatric/psychological treatments

— play therapy

0904 = Behavior Health Treatment/Services

— activity therapy (eff. 10/2004);

prior to 10/2004 defined as

Psychiatric/psychological treatments

— activity therapy

0905 = Behavior Health Treatment/Services

— intensive outpatient services —

psychiatric (eff. 10/2004)

0906 = Behavior Health Treatment/Services

— intensive outpatient services —

chemical dependency (eff. 10/2004)

0907 = Behavior Health Treatment/Services

— community behavioral health

program — day treatment (eff.

10/2004)

0909 = Reserved for National Use (eff.

10/2004); prior to 10/2004 defined

as Psychiatric/psychological

treatments — other

0910 = Behavioral Health

Treatment/Services — Reserved for

National Assignment (eff. 10/2004);

prior to 10/2004 defined as

Psychiatric/psychological services

— general classification

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0911 = Behavioral Health

Treatment/Services —

rehabilitation (eff. 10/2004);

prior to 10/2004 defined as

Psychiatric/psychological

services — rehabilitation

0912 = Behavioral Health

Treatment/Services — partial

hospitalization — less intensive

(eff. 10/2004); prior to 10/2004

defined as

Psychiatric/psychological

services — less intensive

0913 = Behavioral Health

Treatment/Services — partial

hospitalization — intensive (eff.

10/2004); prior to 10/2004

defined as

Psychiatric/psychological

services — intensive

0914 = Behavioral Health

Treatment/Services — individual

therapy (eff. 10/2004) prior to

10/2004 defined as

Psychiatric/psychological

services — individual therapy

0915 = Behavioral Health

Treatment/Services — group

therapy (eff. 10/2004); prior to

10/2004 defined as

Psychiatric/psychological

services — group therapy

0916 = Behavioral Health

Treatment/Services — family

therapy (eff. 10/2004); prior to

10/2004 defined as

Psychiatric/psychological

services — family therapy

0917 = Behavioral Health Treatment/Services

— biofeedback (eff. 10/2004); prior to

10/2004 defined as

Psychiatric/psychological services —

biofeedback

0918 = Behavioral Health Treatment/Services

— testing (eff. 10/2004); prior to

10/2004 defined as

Psychiatric/psychological services —

testing

0919 = Behavioral Health Treatment/Services

— other (eff. 10/2004); prior to

10/2004 defined as

Psychiatric/psychological services —

other

0920 = Other diagnostic services — general

classification

0921 = Other diagnostic services — peripheral

vascular lab

0922 = Other diagnostic services —

electromyelogram

0923 = Other diagnostic services — pap smear

0924 = Other diagnostic services — allergy test

0925 = Other diagnostic services — pregnancy

test

0929 = Other diagnostic services — other

0931 = Medical Rehabilitation Day Program —

half day

0932 = Medical Rehabilitation Day Program —

Full Day

0940 = Other therapeutic services — general

classification

0941 = Other therapeutic services —

recreational therapy

0942 = Other therapeutic services —

education/training (include

diabetes diet training)

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0943 = Other therapeutic services —

cardiac rehabilitation

0944 = Other therapeutic services —

drug rehabilitation

0945 = Other therapeutic services —

alcohol rehabilitation

0946 = Other therapeutic services —

routine complex medical

equipment

0947 = Other therapeutic services —

ancillary complex medical

equipment

0948 = Other therapeutic services —

pulmonary rehab

0949 = Other therapeutic services —

other

0951 = Other therapeutic services —

athletic training (extension of

094X)

0952 = Other therapeutic services —

kinesiotherapy (extension of

094X)

0953 = Other therapeutic services —

chemical dependency (drug and

alcohol) (extension of 094X)

0958 = Reserved other, therapeutic

services, extension of 094X

0960 = Professional fees — general

classification

0961 = Professional fees — psychiatric

0962 = Professional fees —

ophthalmology

0963 = Professional fees —

anesthesiologist (MD)

0964 = Professional fees —

anesthetist (CRNA)

0969 = Professional fees — other (NOTE:

097X is an extension of 096X)

0971 = Professional fees — laboratory

0972 = Professional fees — radiology

diagnostic

0973 = Professional fees — radiology

therapeutic

0974 = Professional fees — nuclear medicine

0975 = Professional fees — operating room

0976 = Professional fees — respiratory

therapy

0977 = Professional fees — physical therapy

0978 = Professional fees — occupational

therapy

0979 = Professional fees — speech pathology

(NOTE: 098X is an extension of 096X

and 097X)

0981 = Professional fees — emergency room

0982 = Professional fees — outpatient

services

0983 = Professional fees — clinic

0984 = Professional fees — medical social

services

0985 = Professional fees — EKG

0986 = Professional fees — EEG

0987 = Professional fees — hospital visit

0988 = Professional fees — consultation

0989 = Professional fees — private duty

nurse

0990 = Patient convenience items —

general classification

0991 = Patient convenience items —

cafeteria/guest tray

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0992 = Patient convenience items —

private linen service

0993 = Patient convenience items —

telephone/telegraph

0994 = Patient convenience items —

tv/radio

0995 = Patient convenience items —

nonpatient room rentals

0996 = Patient convenience items —

late discharge charge

0997 = Patient convenience items —

admission kits

0998 = Patient convenience items —

beauty shop/barber

0999 = Patient convenience items —

other

1000 = Behavioral health

Accommodations — general

1001 = Behavioral health

Accommodations — residential

treatment psychiatric

1002 = Behavioral health

Accommodations — residential

treatment chemical dependency

1003= Behavioral health

Accommodations — Supervised

living

1004 = Behavioral health

Accommodations — Halfway

House

1005 = Behavioral health

Accommodations — Group

Home

1006 = Behavioral health

Accommodations —

Outdoor/wilderness behavioral

health (eff. 7/1/17)

2100 = Alternative Therapy Services — General

2101 = Alternative Therapy Services — Acupuncture

2102 = Alternative Therapy Services — Acupressure

2103 = Alternative Therapy Services — Massage

2104 = Alternative Therapy Services — Reflexology

2105 = Alternative Therapy Services — Biofeedback

2106 = Alternative Therapy Services — Hypnosis

2109 = Alternative Therapy Services — Other

3101 = Adult Day Care — Medical and Social

(hourly)

3103 = Adult Day Care — Medical and Social (daily)

3104 = Adult Day Care — Social (daily)

3105 = Adult Foster Care (daily)

3109 = Adult Day Care — other

NOTE: Following Revenue Codes reported for

NHCMQ (RUGS) demo claims eff. 2/96

9000 = RUGS — no MDS assessment

available

9001 = Reduced physical functions —

RUGS PA1/ADL index of 4–5

9002 = Reduced physical functions —

RUGS PA2/ADL index of 4–5

9003 = Reduced physical functions —

RUGS PB1/ADL index of 6–8

9004 = Reduced physical functions —

RUGS PB2/ADL index of 6–8

9005 = Reduced physical functions —

RUGS PC1/ADL index of 9–10

9006 = Reduced physical functions —

RUGS PC2/ADL index of 9–10

9007 = Reduced physical functions — RUGS

PD1/ADL index of 11–15

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9008 = Reduced physical functions —

RUGS PD2/ADL index of 11–15

9009 = Reduced physical functions —

RUGS PE1/ADL index of 16–18

9010 = Reduced physical functions —

RUGS PE2/ADL index of 16–18

9011 = Behavior only problems —

RUGS BA1/ADL index of 4–5

9012 = Behavior only problems —

RUGS BA2/ADL index of 4–5

9013 = Behavior only problems —

RUGS BB1/ADL index of 6–10

9014 = Behavior only problems —

RUGS BB2/ADL index of 6–10

9015 = Impaired cognition — RUGS

IA1/ADL index of 4–5

9016 = Impaired cognition — RUGS

IA2/ADL index of 4–5

9017 = Impaired cognition — RUGS

IB1/ADL index of 6–10

9018 = Impaired cognition — RUGS

IB2/ADL index of 6–10

9019 = Clinically complex — RUGS

CA1/ADL index of 4–5

9020 = Clinically complex — RUGS

CA2/ADL index of 4–5d

9021 = Clinically complex — RUGS

CB1/ADL index of 6–10

9022 = Clinically complex — RUGS

CB2/ADL index of 6–10d

9023 = Clinically complex — RUGS

CC1/ADL index of 11–16

9024 = Clinically complex — RUGS

CC2/ADL index of 11–16d

9025 = Clinically complex — RUGS

CD1/ADL index of 17–18

9026 = Clinically complex — RUGS

CD2/ADL index of 17–18d

9027 = Special care — RUGS SSA/ADL

index of 7–13

9028 = Special care — RUGS SSB/ADL

index of 14–16

9029 = Special care — RUGS SSC/ADL

index of 17-–18

9030 = Extensive services — RUGS SE1/1

procedure

9031 = Extensive services — RUGS SE2/2

procedures

9032 = Extensive services — RUGS SE3/3

procedures

9033 = Low rehabilitation — RUGS

RLA/ADL index of 4–11

9034 = Low rehabilitation — RUGS

RLB/ADL index of 12–18

9035 = Medium rehabilitation — RUGS

RMA/ADL index of 4-7

9036 = Medium rehabilitation — RUGS

RMB/ADL index of 8–15

9037 = Medium rehabilitation — RUGS

RMC/ADL index of 16–18

9038 = High rehabilitation — RUGS

RHA/ADL index of 4–7

9039 = High rehabilitation — RUGS

RHB/ADL index of 8–11

9040 = High rehabilitation — RUGS

RHC/ADL index of 12–14

9041 = High rehabilitation — RUGS

RHD/ADL index of 15–18

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9042 = Very high rehabilitation —

RUGS RVA/ADL index of 4–7

9043 = Very high rehabilitation —

RUGS RVB/ADL index of 8–13

9044 = Very high rehabilitation —

RUGS RVC/ADL index of 14–18

***Changes effective for providers entering***

**RUGS Demo Phase III as of 1/1/1997 or later**

9019 = Clinically complex — RUGS

CA1/ADL index of 11

9020 = Clinically complex — RUGS

CA2/ADL index of 11D

9021 = Clinically complex — RUGS

CB1/ADL index of 12-16

9022 = Clinically complex — RUGS

CB2/ADL index of 12-16D

9023 = Clinically complex — RUGS

CC1/ADL index of 17-18

9024 = Clinically complex — RUGS

CC2/ADL index of 17-18D

9025 = Special care — RUGS SSA/ADL

index of 14

9026 = Special care — RUGS SSB/ADL

index of 15–16

9027 = Special care — RUGS SSC/ADL

index of 17–18

9028 = Extensive services — RUGS

SE1/ADL index 7–18/1

procedure

9029 = Extensive services — RUGS

SE2/ADL index 7–18/2

procedures

9030 = Extensive services — RUGS

SE3/ADL index 7–18/3

procedures

9031 = Low rehabilitation — RUGS

RLA/ADL index of 4–13

9032 = Low rehabilitation — RUGS

RLB/ADL index of 14–18

9033 = Low rehabilitation — RUGS

RLA/ADL index of 4–11

9034 = Medium rehabilitation —

RUGS RMB/ADL index of 8–14

9035 = Medium rehabilitation —

RUGS RMC/ADL index of 15–18

9036 = High rehabilitation — RUGS

RHA/ADL index of 4–7

9037 = High rehabilitation — RUGS

RHB/ADL index of 8–12

9038 = High rehabilitation — RUGS

RHC/ADL index of 13–18

9039 = Very High rehabilitation —

RUGS RVA/ADL index of 4–8

9040 = Very high rehabilitation-RUGS

RVB/ADL index of 9–15

9041 = Very high rehabilitation —

RUGS RVC/ADL index of 16

9042 = Very high rehabilitation —

RUGS RUA/ADL index of 4–8

9043 = Very high rehabilitation —

RUGS RUB/ADL index of 9–15

9044 = Ultra high rehabilitation —

RUGS RUC/ADL index of 16–18

COMMENT: — ^ Back to TOC ^

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 353

REV_CNTR_1ST_ANSI_CD

LABEL: Revenue Center 1st ANSI Code

DESCRIPTION: The first code used to identify the detailed reason an adjustment was made (e.g., reason for denial or

reducing payment).

SHORT NAME: REVANSI1

LONG NAME: REV_CNTR_1ST_ANSI_CD

TYPE: CHAR

LENGTH: 5

SOURCE: NCH

VALUES: This code set is an external code set maintained by X12 https://x12.org/codes

*******EXPLANATION OF CLAIM ADJUSTMENT GROUP CODES. List may not be complete or current*******

**************POSITIONS 1 and 2 OF ANSI CODE***************

CO = Contractual Obligations — this

group code should be used when

a contractual agreement between

the payer and payee, or a

regulatory requirement, resulted

in an adjustment. Generally, these

adjustments are considered a

write-off for the provider and are

not billed to the patient

CR = Corrections and Reversals — this

group code should be used for

correcting a prior claim. It applies

when there is a change to a

previously adjudicated claim

OA = Other Adjustments — this group

code should be used when no

other group code applies to the

adjustment

PI = Payer Initiated Reductions — this

group code should be used when,

in the opinion of the payer, the

adjustment is not the

responsibility of the patient, but

there is no supporting contract

between the provider and the

payer (i.e., medical review or

professional review organization

adjustments)

PR = Patient Responsibility — this group

should be used when the

adjustment represents an amount

that should be billed to the patient

or insured. This group would

typically be used for deductible

and copay adjustments

***********Claim Adjustment Reason Codes***************

***********POSITIONS 3 through 5 of ANSI CODE**********

1 = Deductible Amount

2 = Coinsurance Amount

3 = Co-pay Amount

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4 = The procedure code is

inconsistent with the modifier

used or a required modifier is

missing

5 = The procedure code/bill type is

inconsistent with the place of

service

6 = The procedure code is inconsistent

with the patient's age

7 = The procedure code is inconsistent

with the patient's gender

8 = The procedure code is inconsistent

with the provider type

9 = The diagnosis is inconsistent with

the patient's age

10 = The diagnosis is inconsistent with

the patient's gender

11 = The diagnosis is inconsistent with

the procedure

12 = The diagnosis is inconsistent with

the provider type

13 = The date of death precedes the

date of service

14 = The date of birth follows the date

of service

15 = Claim/service adjusted because

the submitted authorization

number is missing, invalid, or does

not apply to the billed services or

provider

16 = Claim/service lacks information

which is needed for adjudication

17 = Claim/service adjusted because

requested information was not

provided or was

insufficient/incomplete

18 = Duplicate claim/service

19 = Claim denied because this is a

work-related injury/illness and thus

the liability of the Worker's

Compensation carrier

20 = Claim denied because this

injury/illness is covered by the

liability carrier

21 = Claim denied because this

injury/illness is the liability of the no-

fault carrier

22 = Claim adjusted because this care

may be covered by another payer

per coordination of benefits

23 = Claim adjusted because charges

have been paid by another payer

24 = Payment for charges adjusted.

Charges are covered under a

capitation agreement/managed care

plan

25 = Payment denied. Your Stop loss

deductible has not been met

26 = Expenses incurred prior to

coverage

27 = Expenses incurred after coverage

terminated

28 = Coverage not in effect at the time

the service was provided

29 = The time limit for filing has expired

30 = Claim/service adjusted because the

patient has not met the required

eligibility, spend down, waiting, or

residency requirements

31 = Claim denied as patient cannot be

identified as our insured

32 = Our records indicate that this

dependent is not an eligible

dependent as defined

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33 = Claim denied. Insured has no

dependent coverage

34 = Claim denied. Insured has no

coverage for newborns

35 = Benefit maximum has been

reached

36 = Balance does not exceed

copayment amount

37 = Balance does not exceed

deductible amount

38 = Services not provided or

authorized by designated (network)

providers

39 = Services denied at the time

authorization/pre-certification was

requested

40 = Charges do not meet

qualifications for

emergency/urgent care

41 = Discount agreed to in Preferred

Provider contract

42 = Charges exceed our fee schedule

or maximum allowable amount

43 = Gramm-Rudman reduction

44 = Prompt-pay discount

45 = Charges exceed your

contracted/legislated fee

arrangement

46 = This (these) service(s) is(are) not

covered

47 = This (these) diagnosis(es) is(are)

not covered, missing, or are invalid

48 = This (these) procedure(s) is(are)

not covered

49 = These are non-covered services

because this is a routine exam or

screening procedure done in

conjunction with a routine exam

50 = These are non-covered services

because this is not deemed a

“medical necessity” by the payer

51 = These are non-covered services

because this a pre-existing

condition

52 = The referring/prescribing/

rendering provider is not eligible to

refer/prescribe/order/perform the

service billed

53 = Services by an immediate relative or

a member of the same household

are not covered

54 = Multiple physicians/assistants are

not covered in this case

55 = Claim/service denied because

procedure/treatment is deemed

experimental/investigational by the

payer

56 = Claim/service denied because

procedure/treatment has not been

deemed “proven to be effective” by

payer

57 = Claim/service adjusted because the

payer deems the information

submitted does not support this

level of service, this many services,

this length of service, or this dosage

58 = Claim/service adjusted because

treatment was deemed by the

payer to have been rendered in an

inappropriate or invalid place of

service

59 = Charges are adjusted based on

multiple surgery rules or concurrent

anesthesia rules

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 356

60 = Charges for outpatient services

with the proximity to inpatient

services are not covered

61 = Charges adjusted as penalty for

failure to obtain second surgical

opinion

62 = Claim/service denied/reduced

for absence of, or exceeded,

precertification/authorization

63 = Correction to a prior claim.

INACTIVE

64 = Denial reversed per Medical

Review. INACTIVE

65 = Procedure code was incorrect.

This payment reflects the correct

code. INACTIVE

66 = Blood Deductible

67 = Lifetime reserve days. INACTIVE

68 = DRG weight. INACTIVE

69 = Day outlier amount

70 = Cost outlier amount

71 = Primary Payer amount

72 = Coinsurance day. INACTIVE

73 = Administrative days. INACTIVE

74 = Indirect Medical Education

Adjustment

75 = Direct Medical Education

Adjustment

76 = Disproportionate Share

Adjustment

77 = Covered days. INACTIVE

78 = Non-covered days/room charge

adjustment

79 = Cost report days. INACTIVE

80 = Outlier days. INACTIVE

81 = Discharges. INACTIVE

82 = PIP days. INACTIVE

83 = Total visits. INACTIVE

84 = Capital adjustments. INACTIVE

85 = Interest amount. INACTIVE

86 = Statutory adjustment. INACTIVE

87 = Transfer amounts

88 = Adjustment amount represents collection against

receivable created in prior overpayment

89 = Professional fees removed from charges

90 = Ingredient cost adjustment

91 = Dispensing fee adjustment

92 = Claim paid in full. INACTIVE

93 = No claim level adjustment. INACTIVE

94 = Process in excess of charges

95 = Benefits adjusted. Plan procedures not

followed

96 = Non-covered charges

97 = Payment is included in allowance for

another service/procedure

98 = The hospital must file the Medicare

claim for this inpatient non-physician

service. INACTIVE

99 = Medicare Secondary Payer Adjustment

Amount. INACTIVE

100 = Payment made to

patient/insured/responsible party

101 = Predetermination: anticipated

payment upon completion of

services or claim adjudication

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 357

102 = Major medical adjustment

103 = Provider promotional

discount (i.e., Senior citizen

discount)

104 = Managed care withholding

105 = Tax withholding

106 = Patient payment option/election

not in effect

107 = Claim/service denied because

the related or qualifying

claim/service was not paid or

identified on the claim

108 = Claim/service reduced because

rent/purchase guidelines were

not met

109 = Claim not covered by this

payer/contractor. You must send

the claim to the correct

payer/contractor

110 = Billing date predates service date

111 = Not covered unless the provider

accepts assignment

112 = Claim/service adjusted as not

furnished directly to the patient

and/or not documented

113 = Claim denied because

service/procedure was provided

outside the United States or as a

result of war

114 = Procedure/Product not

approved by the Food and Drug

Administration

115 = Claim/service adjusted as

procedure postponed or

canceled

116 = Claim/service denied. The advance

indemnification notice signed by the

patient did not comply with

requirements

117 = Claim/service adjusted because

transportation is only covered to the

closest facility that can provide the

necessary care

118 = Charges reduced for ESRD network

support

119 = Benefit maximum for this time

period has been reached

120 = Patient is covered by a managed

care plan. INACTIVE

121 = Indemnification adjustment

122 = Psychiatric reduction

123 = Payer refund due to overpayment.

INACTIVE

124 = Payer refund amount — not our

patient. INACTIVE

125 = Claim/service adjusted due to a

submission/billing error(s)

126 = Deductible — major Medical

127 = Coinsurance — major Medical

128 = Newborn's services are covered in

the mother's allowance

129 = Claim denied — prior processing

information appears incorrect

130 = Paper claim submission fee

131 = Claim specific negotiated discount

132 = Prearranged demonstration project

adjustment

133 = The disposition of this claim/service

is pending further review

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 358

134 = Technical fees removed from

charges

135 = Claim denied. Interim bills

cannot be processed

136 = Claim adjusted. Plan

procedures of a prior payer

were not followed

137 = Payment/Reduction for

Regulatory Surcharges,

Assessments, Allowances or

Health Related Taxes

138 = Claim/service denied. Appeal

procedures not followed, or time

limits not met

139 = Contracted funding agreement

— subscriber is employed by the

provider of services

140 = Patient/Insured health

identification number and name

do not match

141 = Claim adjustment because the

claim spans eligible and ineligible

periods of coverage

142 = Claim adjusted by the monthly

Medicaid patient liability amount

A0 = Patient refund amount

A1 = Claim denied charges

A2 = Contractual adjustment

A3 = Medicare Secondary Payer

liability met. INACTIVE

A4 = Medicare Claim PPS Capital Day

Outlier Amount

A5 = Medicare Claim PPS Capital Cost

Outlier Amount

A6 = Prior hospitalization or 30-day

transfer requirement not met

A7 = Presumptive Payment Adjustment

A8 = Claim denied; ungroupable DRG

B1 = Non-covered visits

B2 = Covered visits. INACTIVE

B3 = Covered charges. INACTIVE

B4 = Late filing penalty

B5 = Claim/service adjusted because

coverage/program guidelines were

not met or were exceeded

B6 = This service/procedure is adjusted

when performed/billed by this type

of provider, by this type of facility, or

by a provider of this specialty

B7 = This provider was not

certified/eligible to be paid for this

procedure/service on this date of

service

B8 = Claim/service not covered/reduced

because alternative services were

available and should have been

utilized

B9 = Services not covered because the

patient is enrolled in a Hospice

B10 = Allowed amount has been reduced

because a component of the basic

procedure/test was paid. The

beneficiary is not liable for more

than the charge limit for the basic

procedure/test

B11 = The claim/service has been

transferred to the proper

payer/processor for processing.

Claim/service not covered by this

payer/processor

B12 = Services not documented in

patients' medical records

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 359

B13 = Previously paid. Payment for

this claim/service may have

been provided in a previous

payment

B14 = Claim/service denied because

only one visit or consultation

per physician per day is covered

B15 = Claim/service adjusted because

this procedure/service is not

paid separately

B16 = Claim/service adjusted because

“New Patient” qualifications

were not met

B17 = Claim/service adjusted because

this service was not prescribed

by a physician, not prescribed

prior to delivery, the prescription

is incomplete, or the prescription

is not current

B18 = Claim/service denied because

this procedure code/modifier

was invalid on the date of

service or claim submission

B19 = Claim/service adjusted

because of the finding of a

Review Organization. INACTIVE

B20 = Charges adjusted because

procedure/service was partially

or fully furnished by another

provider

B21 = The charges were reduced

because the service/care was

partially furnished by another

physician. INACTIVE

B22 = This claim/service is adjusted

based on the diagnosis

B23 = Claim/service denied because

this provider has failed an

aspect of a proficiency testing

program

W1 = Workers Compensation State

Fee Schedule Adjustment

COMMENT: This field is populated for those claims that are required to process through outpatient PPS PRICER

software. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland

providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical

Access Hospitals [CAH]); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of

bill with a condition code “07” and certain HCPCS. These claim types could have lines that are not

required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services

with dates of service 1/2002 and forward.

Valid beginning with NCH weekly process date 7/2000.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 360

REV_CNTR_1ST_MSP_PD_AMT

LABEL: Revenue Center 1st Medicare Secondary Payer (MSP) Paid Amount

DESCRIPTION: The amount paid by the primary payer when the payer is primary to Medicare (Medicare is a

secondary).

SHORT NAME: REV_MSP1

LONG NAME: REV_CNTR_1ST_MSP_PD_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: This field is populated for those claims that are required to process through outpatient PPS PRICER

software. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland

providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical

Access Hospitals [CAH]); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of

bill with a condition code “07” and certain HCPCS. These claim types could have lines that are not

required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services

with dates of service 1/2002 and forward.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 361

REV_CNTR_2ND_ANSI_CD

LABEL: Revenue Center 2nd ANSI Code

DESCRIPTION: The second code used to identify the detailed reason an adjustment was made (e.g., reason for denial

or reducing payment).

SHORT NAME: REVANSI2

LONG NAME: REV_CNTR_2ND_ANSI_CD

TYPE: CHAR

LENGTH: 5

SOURCE: NCH

VALUES: *******EXPLANATION OF CLAIM ADJUSTMENT GROUP CODES*******

**************POSITIONS 1 and 2 OF ANSI CODE***************

CO = Contractual Obligations — this

group code should be used when

a contractual agreement between

the payer and payee, or a

regulatory requirement, resulted

in an adjustment. Generally, these

adjustments are considered a

write-off for the provider and are

not billed to the patient

CR = Corrections and Reversals — this

group code should be used for

correcting a prior claim. It applies

when there is a change to a

previously adjudicated claim

OA = Other Adjustments — this group code should be

used when no other group code applies to the

adjustment

PI = Payer Initiated Reductions — this group code

should be used when, in the opinion of the payer,

the adjustment is not the responsibility of the

patient, but there is no supporting contract

between the provider and the payer (i.e., medical

review or professional review organization

adjustments)

PR = Patient Responsibility — this group should be

used when the adjustment represents an amount

that should be billed to the patient or insured.

This group would typically be used for deductible

and copay adjustments

***********Claim Adjustment Reason Codes***************

***********POSITIONS 3 through 5 of ANSI CODE**********

1 = Deductible Amount

2 = Coinsurance Amount

3 = Co-pay Amount

4 = The procedure code is inconsistent with the

modifier used or a required modifier is missing

5 = The procedure code/bill type is inconsistent with

the place of service

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 362

6 = The procedure code is inconsistent

with the patient's age

7 = The procedure code is inconsistent

with the patient's gender

8 = The procedure code is inconsistent

with the provider type

9 = The diagnosis is inconsistent with

the patient's age

10 = The diagnosis is inconsistent with

the patient's gender

11 = The diagnosis is inconsistent with

the procedure

12 = The diagnosis is inconsistent with

the provider type

13 = The date of death precedes the

date of service

14 = The date of birth follows the date

of service

15 = Claim/service adjusted because

the submitted authorization

number is missing, invalid, or does

not apply to the billed services or

provider

16 = Claim/service lacks information

which is needed for adjudication

17 = Claim/service adjusted because

requested information was not

provided or was

insufficient/incomplete

18 = Duplicate claim/service

19 = Claim denied because this is a

work-related injury/illness and thus

the liability of the Worker's

Compensation carrier

20 = Claim denied because this

injury/illness is covered by the

liability carrier

21 = Claim denied because this injury/illness is

the liability of the no-fault carrier

22 = Claim adjusted because this care may be

covered by another payer per

coordination of benefits

23 = Claim adjusted because charges have

been paid by another payer

24 = Payment for charges adjusted. Charges

are covered under a capitation

agreement/managed care plan

25 = Payment denied. Your Stop loss

deductible has not been met

26 = Expenses incurred prior to coverage

27 = Expenses incurred after coverage

terminated

28 = Coverage not in effect at the time the

service was provided

29 = The time limit for filing has expired

30 = Claim/service adjusted because the

patient has not met the required

eligibility, spend down, waiting, or

residency requirements

31 = Claim denied as patient cannot be

identified as our insured

32 = Our records indicate that this dependent

is not an eligible dependent as defined

33 = Claim denied. Insured has no dependent

coverage

34 = Claim denied. Insured has no coverage

for newborns

35 = Benefit maximum has been reached

36 = Balance does not exceed copayment

amount

37 = Balance does not exceed deductible

amount

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 363

38 = Services not provided or

authorized by designated

(network) providers

39 = Services denied at the time

authorization/pre-certification

was requested

40 = Charges do not meet

qualifications for

emergency/urgent care

41 = Discount agreed to in Preferred

Provider contract

42 = Charges exceed our fee schedule

or maximum allowable amount

43 = Gramm-Rudman reduction

44 = Prompt-pay discount

45 = Charges exceed your

contracted/legislated fee

arrangement

46 = This (these) service(s) is(are) not

covered

47 = This (these) diagnosis(es) is(are)

not covered, missing, or are

invalid

48 = This (these) procedure(s) is(are)

not covered

49 = These are non-covered services

because this is a routine exam or

screening procedure done in

conjunction with a routine exam

50 = These are non-covered services

because this is not deemed a

“medical necessity” by the payer

51 = These are non-covered services

because this a pre-existing

condition

52 = The referring/prescribing/

rendering provider is not eligible to

refer/prescribe/order/perform the

service billed

53 = Services by an immediate relative or

a member of the same household

are not covered

54 = Multiple physicians/assistants are

not covered in this case

55 = Claim/service denied because

procedure/treatment is deemed

experimental/investigational by the

payer

56 = Claim/service denied because

procedure/treatment has not been

deemed “proven to be effective” by

payer

57 = Claim/service adjusted because the

payer deems the information

submitted does not support this

level of service, this many services,

this length of service, or this dosage

58 = Claim/service adjusted because

treatment was deemed by the payer

to have been rendered in an

inappropriate or invalid place of

service

59 = Charges are adjusted based on

multiple surgery rules or concurrent

anesthesia rules

60 = Charges for outpatient services with

the proximity to inpatient services

are not covered

61 = Charges adjusted as penalty for

failure to obtain second surgical

opinion

62 = Claim/service denied/reduced for

absence of, or exceeded,

precertification/authorization

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 364

63 = Correction to a prior claim.

INACTIVE

64 = Denial reversed per Medical

Review. INACTIVE

65 = Procedure code was incorrect.

This payment reflects the correct

code. INACTIVE

66 = Blood Deductible

67 = Lifetime reserve days. INACTIVE

68 = DRG weight. INACTIVE

69 = Day outlier amount

70 = Cost outlier amount

71 = Primary Payer amount

72 = Coinsurance day. INACTIVE

73 = Administrative days. INACTIVE

74 = Indirect Medical Education

Adjustment

75 = Direct Medical Education

Adjustment

76 = Disproportionate Share

Adjustment

77 = Covered days. INACTIVE

78 = Non-covered days/room charge

adjustment

79 = Cost report days. INACTIVE

80 = Outlier days. INACTIVE

81 = Discharges. INACTIVE

82 = PIP days. INACTIVE

83 = Total visits. INACTIVE

84 = Capital adjustments. INACTIVE

85 = Interest amount. INACTIVE

86 = Statutory adjustment. INACTIVE

87 = Transfer amounts

88 = Adjustment amount represents

collection against receivable

created in prior overpayment

89 = Professional fees removed from

charges

90 = Ingredient cost adjustment

91 = Dispensing fee adjustment

92 = Claim paid in full. INACTIVE

93 = No claim level adjustment.

INACTIVE

94 = Process in excess of charges

95 = Benefits adjusted. Plan procedures

not followed

96 = Non-covered charges

97 = Payment is included in allowance

for another service/procedure

98 = The hospital must file the Medicare

claim for this inpatient non-

physician service. INACTIVE

99 = Medicare Secondary Payer

Adjustment Amount. INACTIVE

100 = Payment made to

patient/insured/responsible party

101 = Predetermination: anticipated

payment upon completion of

services or claim adjudication

102 = Major medical adjustment

103 = Provider promotional discount

(i.e., senior citizen discount)

104 = Managed care withholding

105 = Tax withholding

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 365

106 = Patient payment option/election

not in effect

107 = Claim/service denied because

the related or qualifying

claim/service was not paid or

identified on the claim

108 = Claim/service reduced because

rent/purchase guidelines were

not met

109 = Claim not covered by this

payer/contractor. You must send

the claim to the correct

payer/contractor

110 = Billing date predates service date

111 = Not covered unless the provider

accepts assignment

112 = Claim/service adjusted as not

furnished directly to the patient

and/or not documented

113 = Claim denied because

service/procedure was provided

outside the United States or as a

result of war

114 = Procedure/Product not

approved by the Food and Drug

Administration

115 = Claim/service adjusted as

procedure postponed or

canceled

116 = Claim/service denied. The

advance indemnification notice

signed by the patient did not

comply with requirements

117 = Claim/service adjusted because

transportation is only covered to

the closest facility that can

provide the necessary care

118 = Charges reduced for ESRD network

support

119 = Benefit maximum for this time

period has been reached

120 = Patient is covered by a managed

care plan. INACTIVE

121 = Indemnification adjustment

122 = Psychiatric reduction

123 = Payer refund due to overpayment.

INACTIVE

124 = Payer refund amount — not our

patient. INACTIVE

125 = Claim/service adjusted due to a

submission/billing error(s)

126 = Deductible — Major Medical

127 = Coinsurance — Major Medical

128 = Newborn's services are covered in

the mother's allowance

129 = Claim denied — prior processing

information appears incorrect

130 = Paper claim submission fee

131 = Claim specific negotiated discount.

132 = Prearranged demonstration

project adjustment

133 = The disposition of this

claim/service is pending further

review

134 = Technical fees removed from

charges

135 = Claim denied. Interim bills cannot

be processed

136 = Claim adjusted. Plan procedures of

a prior payer were not followed

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 366

137 = Payment/Reduction for

Regulatory Surcharges,

Assessments, Allowances or

Health Related Taxes

138 = Claim/service denied. Appeal

procedures not followed, or time

limits not met

139 = Contracted funding agreement

— subscriber is employed by the

provider of services

140 = Patient/Insured health

identification number and name

do not match

141 = Claim adjustment because the

claim spans eligible and ineligible

periods of coverage

142 = Claim adjusted by the monthly

Medicaid patient liability amount

A0 = Patient refund amount

A1 = Claim denied charges

A2 = Contractual adjustment

A3 = Medicare Secondary Payer

liability met. INACTIVE

A4 = Medicare Claim PPS Capital Day

Outlier Amount.

A5 = Medicare Claim PPS Capital Cost

Outlier Amount

A6 = Prior hospitalization or 30-day

transfer requirement not met

A7 = Presumptive Payment Adjustment

A8 = Claim denied; ungroupable DRG

B1 = Non-covered visits

B2 = Covered visits. INACTIVE

B3 = Covered charges. INACTIVE

B4 = Late filing penalty

B5 = Claim/service adjusted because

coverage/program guidelines were

not met or were exceeded

B6 = This service/procedure is adjusted

when performed/billed by this type of

provider, by this type of facility, or by

a provider of this specialty

B7 = This provider was not certified/eligible

to be paid for this procedure/service

on this date of service

B8 = Claim/service not covered/reduced

because alternative services were

available and should have been

utilized

B9 = Services not covered because the

patient is enrolled in a hospice

B10 = Allowed amount has been reduced

because a component of the basic

procedure/test was paid. The

beneficiary is not liable for more than

the charge limit for the basic

procedure/test

B11 = The claim/service has been

transferred to the proper

payer/processor for processing.

Claim/service not covered by this

payer/processor

B12 = Services not documented in patients'

medical records

B13 = Previously paid. Payment for this

claim/service may have been

provided in a previous payment

B14 = Claim/service denied because only

one visit or consultation per physician

per day is covered

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 367

B15 = Claim/service adjusted because

this procedure/service is not

paid separately

B16 = Claim/service adjusted because

“New Patient” qualifications

were not met

B17 = Claim/service adjusted because

this service was not prescribed

by a physician, not prescribed

prior to delivery, the prescription

is incomplete, or the prescription

is not current

B18 = Claim/service denied because

this procedure code/modifier

was invalid on the date of

service or claim submission

B19 = Claim/service adjusted because of the

finding of a Review Organization.

INACTIVE

B20 = Charges adjusted because

procedure/service was partially or

fully furnished by another provider

B21 = The charges were reduced because

the service/care was partially

furnished by another physician.

INACTIVE

B22 = This claim/service is adjusted based

on the diagnosis

B23 = Claim/service denied because this

provider has failed an aspect of a

proficiency testing program

W1 = Workers Compensation State Fee

Schedule Adjustment

COMMENT: This field is populated for those claims that are required to process through outpatient PPS PRICER

software. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland

providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical

Access Hospitals [CAH]); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of

bill with a condition code “07” and certain HCPCS. These claim types could have lines that are not

required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services

with dates of service 1/1/2002 and forward.

Valid beginning with NCH weekly process date 7/2000.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 368

REV_CNTR_2ND_MSP_PD_AMT

LABEL: Revenue Center 2nd Medicare Secondary Payer (MSP) Paid Amount

DESCRIPTION: The amount paid by the secondary payer when two payers are primary to Medicare (Medicare is the

tertiary payer).

SHORT NAME: REV_MSP2

LONG NAME: REV_CNTR_2ND_MSP_PD_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: This field is populated for those claims that are required to process through outpatient PPS PRICER

software. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland

providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical

Access Hospitals [CAH]); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of

bill with a condition code “07” and certain HCPCS. These claim types could have lines that are not

required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services

with dates of service 1/1/2002 and forward.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 369

REV_CNTR_3RD_ANSI_CD

LABEL: Revenue Center 3rd ANSI Code

DESCRIPTION: The third code used to identify the detailed reason an adjustment was made (e.g., reason for denial or

reducing payment).

SHORT NAME: REVANSI3

LONG NAME: REV_CNTR_3RD_ANSI_CD

TYPE: CHAR

LENGTH: 5

SOURCE: NCH

VALUES: *******EXPLANATION OF CLAIM ADJUSTMENT GROUP CODES*******

**************POSITIONS 1 and 2 OF ANSI CODE***************

CO = Contractual Obligations — this

group code should be used when

a contractual agreement between

the payer and payee, or a

regulatory requirement, resulted

in an adjustment. Generally, these

adjustments are considered a

write-off for the provider and are

not billed to the patient.

CR = Corrections and Reversals — this

group code should be used for

correcting a prior claim. It applies

when there is a change to a

previously adjudicated claim

OA = Other Adjustments — this group code should be

used when no other group code applies to the

adjustment

PI = Payer Initiated Reductions — this group code

should be used when, in the opinion of the payer,

the adjustment is not the responsibility of the

patient, but there is no supporting contract

between the provider and the payer (i.e., medical

review or professional review organization

adjustments)

PR = Patient Responsibility — this group should be

used when the adjustment represents an amount

that should be billed to the patient or insured.

This group would typically be used for deductible

and copay adjustments

***********Claim Adjustment Reason Codes***************

***********POSITIONS 3 through 5 of ANSI CODE**********

1 = Deductible Amount

2 = Coinsurance Amount

3 = Co-pay Amount

4 = The procedure code is inconsistent

with the modifier used or a

required modifier is missing

5 = The procedure code/bill type is

inconsistent with the place of service

6 = The procedure code is inconsistent

with the patient's age

7 = The procedure code is inconsistent

with the patient's gender

Chronic Conditions Warehouse Virtual Research Data Center

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8 = The procedure code is inconsistent

with the provider type

9 = The diagnosis is inconsistent with

the patient's age

10 = The diagnosis is inconsistent with

the patient's gender

11 = The diagnosis is inconsistent with

the procedure

12 = The diagnosis is inconsistent with

the provider type

13 = The date of death precedes the

date of service

14 = The date of birth follows the date

of service

15 = Claim/service adjusted because

the submitted authorization

number is missing, invalid, or does

not apply to the billed services or

provider

16 = Claim/service lacks information

which is needed for adjudication

17 = Claim/service adjusted because

requested information was not

provided or was

insufficient/incomplete

18 = Duplicate claim/service

19 = Claim denied because this is a

work-related injury/illness and

thus the liability of the Worker's

Compensation carrier

20 = Claim denied because this

injury/illness is covered by the

liability carrier

21 = Claim denied because this

injury/illness is the liability of the

no-fault carrier

22 = Claim adjusted because this care

may be covered by another payer

per coordination of benefits

23 = Claim adjusted because charges

have been paid by another payer

24 = Payment for charges adjusted.

Charges are covered under a

capitation agreement/managed

care plan

25 = Payment denied. Your Stop loss

deductible has not been met

26 = Expenses incurred prior to

coverage

27 = Expenses incurred after coverage

terminated

28 = Coverage not in effect at the time

the service was provided

29 = The time limit for filing has

expired

30 = Claim/service adjusted because

the patient has not met the

required eligibility, spend down,

waiting, or residency

requirements

31 = Claim denied as patient cannot be

identified as our insured

32 = Our records indicate that this

dependent is not an eligible

dependent as defined

33 = Claim denied. Insured has no

dependent coverage

34 = Claim denied. Insured has no

coverage for newborns

35 = Benefit maximum has been

reached

36 = Balance does not exceed

copayment amount

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37 = Balance does not exceed

deductible amount

38 = Services not provided or

authorized by designated

(network) providers

39 = Services denied at the time

authorization/pre-certification

was requested

40 = Charges do not meet

qualifications for

emergency/urgent care

41 = Discount agreed to in Preferred

Provider contract

42 = Charges exceed our fee schedule

or maximum allowable amount

43 = Gramm-Rudman reduction

44 = Prompt-pay discount

45 = Charges exceed your

contracted/legislated fee

arrangement

46 = This (these) service(s) is(are) not

covered

47 = This (these) diagnosis(es) is(are)

not covered, missing, or are

invalid

48 = This (these) procedure(s) is(are)

not covered

49 = These are non-covered services

because this is a routine exam or

screening procedure done in

conjunction with a routine exam

50 = These are non-covered services

because this is not deemed a

“medical necessity” by the payer

51 = These are non-covered services

because this a pre-existing

condition

52 = The referring/prescribing/

rendering provider is not eligible to

refer/prescribe/order/perform the

service billed

53 = Services by an immediate relative

or a member of the same

household are not covered

54 = Multiple physicians/assistants are

not covered in this case

55 = Claim/service denied because

procedure/treatment is deemed

experimental/investigational by the

payer

56 = Claim/service denied because

procedure/treatment has not been

deemed “proven to be effective” by

payer

57 = Claim/service adjusted because the

payer deems the information

submitted does not support this

level of service, this many services,

this length of service, or this dosage

58 = Claim/service adjusted because

treatment was deemed by the

payer to have been rendered in an

inappropriate or invalid place of

service

59 = Charges are adjusted based on

multiple surgery rules or concurrent

anesthesia rules

60 = Charges for outpatient services with

the proximity to inpatient services

are not covered

61 = Charges adjusted as penalty for

failure to obtain second surgical

opinion

62 = Claim/service denied/reduced for

absence of, or exceeded,

precertification/authorization

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63 = Correction to a prior claim.

INACTIVE

64 = Denial reversed per Medical

Review. INACTIVE

65 = Procedure code was incorrect.

This payment reflects the correct

code. INACTIVE

66 = Blood Deductible

67 = Lifetime reserve days. INACTIVE

68 = DRG weight. INACTIVE

69 = Day outlier amount

70 = Cost outlier amount

71 = Primary Payer amount

72 = Coinsurance day. INACTIVE

73 = Administrative days. INACTIVE

74 = Indirect Medical Education

Adjustment

75 = Direct Medical Education

Adjustment

76 = Disproportionate Share

Adjustment

77 = Covered days. INACTIVE

78 = Non-covered days/room charge

adjustment

79 = Cost report days. INACTIVE

80 = Outlier days. INACTIVE

81 = Discharges. INACTIVE

82 = PIP days. INACTIVE

83 = Total visits. INACTIVE

84 = Capital adjustments. INACTIVE

85 = Interest amount. INACTIVE

86 = Statutory adjustment. INACTIVE

87 = Transfer amounts

88 = Adjustment amount represents

collection against receivable created in

prior overpayment

89 = Professional fees removed from

charges

90 = Ingredient cost adjustment

91 = Dispensing fee adjustment

92 = Claim paid in full. INACTIVE

93 = No claim level adjustment. INACTIVE

94 = Process in excess of charges

95 = Benefits adjusted. Plan procedures not

followed

96 = Non-covered charges

97 = Payment is included in allowance for

another service/procedure

98 = The hospital must file the Medicare

claim for this inpatient non-physician

service. INACTIVE

99 = Medicare Secondary Payer Adjustment

Amount. INACTIVE

100 = Payment made to

patient/insured/responsible party

101 = Predetermination: anticipated

payment upon completion of services

or claim adjudication

102 = Major medical adjustment

103 = Provider promotional discount (i.e.,

Senior citizen discount).

104 = Managed care withholding

105 = Tax withholding

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106 = Patient payment option/election

not in effect

107 = Claim/service denied because

the related or qualifying

claim/service was not paid or

identified on the claim

108 = Claim/service reduced because

rent/purchase guidelines were

not met

109 = Claim not covered by this

payer/contractor. You must send

the claim to the correct

payer/contractor

110 = Billing date predates service date

111 = Not covered unless the provider

accepts assignment

112 = Claim/service adjusted as not

furnished directly to the patient

and/or not documented

113 = Claim denied because

service/procedure was provided

outside the United States or as a

result of war

114 = Procedure/Product not

approved by the Food and Drug

Administration

115 = Claim/service adjusted as

procedure postponed or canceled

116 = Claim/service denied. The

advance indemnification notice

signed by the patient did not

comply with requirements

117 = Claim/service adjusted because

transportation is only covered to

the closest facility that can

provide the necessary care

118 = Charges reduced for ESRD

network support

119 = Benefit maximum for this time

period has been reached

120 = Patient is covered by a managed

care plan. INACTIVE

121 = Indemnification adjustment

122 = Psychiatric reduction

123 = Payer refund due to

overpayment. INACTIVE

124 = Payer refund amount — not our

patient. INACTIVE

125 = Claim/service adjusted due to a

submission/billing error(s)

126 = Deductible — Major Medical

127 = Coinsurance — Major Medical

128 = Newborn's services are covered

in the mother's allowance

129 = Claim denied — prior processing

information appears incorrect

130 = Paper claim submission fee

131 = Claim specific negotiated

discount

132 = Prearranged demonstration

project adjustment

133 = The disposition of this

claim/service is pending further

review

134 = Technical fees removed from

charges

135 = Claim denied. Interim bills

cannot be processed

136 = Claim adjusted. Plan procedures

of a prior payer were not

followed

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137 = Payment/Reduction for

Regulatory Surcharges,

Assessments, Allowances or

Health Related Taxes

138 = Claim/service denied. Appeal

procedures not followed, or time

limits not met

139 = Contracted funding agreement

— subscriber is employed by the

provider of services

140 = Patient/Insured health

identification number and name

do not match

141 = Claim adjustment because the

claim spans eligible and ineligible

periods of coverage

142 = Claim adjusted by the monthly

Medicaid patient liability amount

A0 = Patient refund amount

A1 = Claim denied charges

A2 = Contractual adjustment

A3 = Medicare Secondary Payer

liability met. INACTIVE

A4 = Medicare Claim PPS Capital Day

Outlier Amount

A5 = Medicare Claim PPS Capital Cost

Outlier Amount

A6 = Prior hospitalization or 30-day

transfer requirement not met

A7 = Presumptive Payment Adjustment

A8 = Claim denied; ungroupable DRG

B1 = Non-covered visits

B2 = Covered visits. INACTIVE

B3 = Covered charges. INACTIVE

B4 = Late filing penalty

B5 = Claim/service adjusted because

coverage/program guidelines were

not met or were exceeded

B6 = This service/procedure is adjusted

when performed/billed by this

type of provider, by this type of

facility, or by a provider of this

specialty

B7 = This provider was not

certified/eligible to be paid for this

procedure/service on this date of

service

B8 = Claim/service not

covered/reduced because

alternative services were available

and should have been utilized

B9 = Services not covered because the

patient is enrolled in a hospice

B10 = Allowed amount has been

reduced because a component of

the basic procedure/test was paid.

The beneficiary is not liable for

more than the charge limit for the

basic procedure/test

B11 = The claim/service has been

transferred to the proper

payer/processor for processing.

Claim/service not covered by this

payer/processor

B12 = Services not documented in

patients' medical records

B13 = Previously paid. Payment for this

claim/service may have been

provided in a previous payment

B14 = Claim/service denied because

only one visit or consultation per

physician per day is covered

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B15 = Claim/service adjusted because

this procedure/service is not paid

separately

B16 = Claim/service adjusted because

“New Patient” qualifications were

not met

B17 = Claim/service adjusted because

this service was not prescribed by

a physician, not prescribed prior

to delivery, the prescription is

incomplete, or the prescription is

not current

B18 = Claim/service denied because

this procedure code/modifier was

invalid on the date of service or

claim submission

B19 = Claim/service adjusted because of the finding of

a Review Organization. INACTIVE

B20 = Charges adjusted because

procedure/service was partially or

fully furnished by another provider

B21 = The charges were reduced because

the service/care was partially

furnished by another physician.

INACTIVE

B22 = This claim/service is adjusted based

on the diagnosis

B23 = Claim/service denied because this

provider has failed an aspect of a

proficiency testing program

W1 = Workers Compensation State Fee

Schedule Adjustment

COMMENT: This field is populated for those claims that are required to process through outpatient PPS PRICER

software. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland

providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical

Access Hospitals [CAH]); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of

bill with a condition code “07” and certain HCPCS. These claim types could have lines that are not

required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services

with dates of service 1/2002 and forward.

Valid beginning with NCH weekly process date 7/2000.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 376

REV_CNTR_4TH_ANSI_CD

LABEL: Revenue Center 4th ANSI Code

DESCRIPTION: The fourth code used to identify the detailed reason an adjustment was made (e.g., reason for denial

or reducing payment).

SHORT NAME: REVANSI4

LONG NAME: REV_CNTR_4TH_ANSI_CD

TYPE: CHAR

LENGTH: 5

SOURCE: NCH

VALUES: *******EXPLANATION OF CLAIM ADJUSTMENT GROUP CODES*******

**************POSITIONS 1 and 2 OF ANSI CODE***************

CO = Contractual Obligations — this group code should be used when a contractual agreement

between the payer and payee, or a regulatory requirement, resulted in an adjustment. Generally,

these adjustments are considered a write-off for the provider and are not billed to the patient.

CR = Corrections and Reversals — this group code should be used for correcting a prior claim. It

applies when there is a change to a previously adjudicated claim.

OA = Other Adjustments — this group code should be used when no other group code applies to the

adjustment.

PI = Payer Initiated Reductions — this group code should be used when, in the opinion of the payer,

the adjustment is not the responsibility of the patient, but there is no supporting contract between

the provider and the payer (i.e., medical review or professional review organization adjustments).

PR = Patient Responsibility — this group should be used when the adjustment represents an amount

that should be billed to the patient or insured. This group would typically be used for deductible and

copay adjustments.

***********Claim Adjustment Reason Codes***************

***********POSITIONS 3 through 5 of ANSI CODE**********

1 = Deductible Amount

2 = Coinsurance Amount

3 = Co-pay Amount

4 = The procedure code is inconsistent

with the modifier used or a

required modifier is missing

5 = The procedure code/bill type is

inconsistent with the place of service

6 = The procedure code is inconsistent

with the patient's age

7 = The procedure code is inconsistent

with the patient's gender

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8 = The procedure code is inconsistent

with the provider type

9 = The diagnosis is inconsistent with

the patient's age

10 = The diagnosis is inconsistent with

the patient's gender

11 = The diagnosis is inconsistent with

the procedure

12 = The diagnosis is inconsistent with

the provider type

13 = The date of death precedes the

date of service

14 = The date of birth follows the date

of service

15 = Claim/service adjusted because

the submitted authorization

number is missing, invalid, or does

not apply to the billed services or

provider

16 = Claim/service lacks information

which is needed for adjudication

17 = Claim/service adjusted because

requested information was not

provided or was

insufficient/incomplete

18 = Duplicate claim/service

19 = Claim denied because this is a

work-related injury/illness and

thus the liability of the Worker's

Compensation carrier

20 = Claim denied because this

injury/illness is covered by the

liability carrier

21 = Claim denied because this

injury/illness is the liability of the

no-fault carrier

22 = Claim adjusted because this care

may be covered by another payer

per coordination of benefits

23 = Claim adjusted because charges

have been paid by another payer

24 = Payment for charges adjusted.

Charges are covered under a

capitation agreement/managed

care plan

25 = Payment denied. Your Stop loss

deductible has not been met

26 = Expenses incurred prior to

coverage

27 = Expenses incurred after coverage

terminated

28 = Coverage not in effect at the time

the service was provided

29 = The time limit for filing has

expired

30 = Claim/service adjusted because

the patient has not met the

required eligibility, spend down,

waiting, or residency

requirements

31 = Claim denied as patient cannot be

identified as our insured

32 = Our records indicate that this

dependent is not an eligible

dependent as defined

33 = Claim denied. Insured has no

dependent coverage

34 = Claim denied. Insured has no

coverage for newborns

35 = Benefit maximum has been

reached

36 = Balance does not exceed

copayment amount

Chronic Conditions Warehouse Virtual Research Data Center

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37 = Balance does not exceed

deductible amount

38 = Services not provided or

authorized by designated

(network) providers

39 = Services denied at the time

authorization/pre-certification

was requested

40 = Charges do not meet

qualifications for

emergency/urgent care

41 = Discount agreed to in Preferred

Provider contract

42 = Charges exceed our fee schedule

or maximum allowable amount

43 = Gramm-Rudman reduction

44 = Prompt-pay discount

45 = Charges exceed your

contracted/legislated fee

arrangement

46 = This (these) service(s) is(are) not

covered

47 = This (these) diagnosis(es) is(are)

not covered, missing, or are

invalid

48 = This (these) procedure(s) is(are)

not covered

49 = These are non-covered services

because this is a routine exam or

screening procedure done in

conjunction with a routine exam

50 = These are non-covered services

because this is not deemed a

“medical necessity” by the payer

51 = These are non-covered services

because this a pre-existing

condition

52 = The referring/prescribing/

rendering provider is not eligible to

refer/prescribe/order/perform the

service billed

53 = Services by an immediate relative or

a member of the same household

are not covered

54 = Multiple physicians/assistants are

not covered in this case

55 = Claim/service denied because

procedure/treatment is deemed

experimental/investigational by the

payer

56 = Claim/service denied because

procedure/treatment has not been

deemed “proven to be effective” by

payer

57 = Claim/service adjusted because the

payer deems the information

submitted does not support this

level of service, this many services,

this length of service, or this dosage

58 = Claim/service adjusted because

treatment was deemed by the payer

to have been rendered in an

inappropriate or invalid place of

service

59 = Charges are adjusted based on

multiple surgery rules or concurrent

anesthesia rules

60 = Charges for outpatient services with

the proximity to inpatient services

are not covered

61 = Charges adjusted as penalty for

failure to obtain second surgical

opinion

62 = Claim/service denied/reduced for

absence of, or exceeded,

precertification/authorization

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63 = Correction to a prior claim.

INACTIVE

64 = Denial reversed per Medical

Review. INACTIVE

65 = Procedure code was incorrect.

This payment reflects the correct

code. INACTIVE

66 = Blood Deductible

67 = Lifetime reserve days. INACTIVE

68 = DRG weight. INACTIVE

69 = Day outlier amount

70 = Cost outlier amount

71 = Primary Payer amount

72 = Coinsurance day. INACTIVE

73 = Administrative days. INACTIVE

74 = Indirect Medical Education

Adjustment

75 = Direct Medical Education

Adjustment

76 = Disproportionate Share

Adjustment

77 = Covered days. INACTIVE

78 = Non-covered days/room charge

adjustment.

79 = Cost report days. INACTIVE

80 = Outlier days. INACTIVE

81 = Discharges. INACTIVE

82 = PIP days. INACTIVE

83 = Total visits. INACTIVE

84 = Capital adjustments. INACTIVE

85 = Interest amount. INACTIVE

86 = Statutory adjustment. INACTIVE

87 = Transfer amounts

88 = Adjustment amount represents

collection against receivable created

in prior overpayment

89 = Professional fees removed from

charges

90 = Ingredient cost adjustment

91 = Dispensing fee adjustment

92 = Claim paid in full. INACTIVE

93 = No claim level adjustment. INACTIVE

94 = Process in excess of charges

95 = Benefits adjusted. Plan procedures

not followed

96 = Non-covered charges

97 = Payment is included in allowance for

another service/procedure

98 = The hospital must file the Medicare

claim for this inpatient non-physician

service. INACTIVE

99 = Medicare Secondary Payer

Adjustment Amount. INACTIVE

100 = Payment made to

patient/insured/responsible party

101 = Predetermination: anticipated

payment upon completion of services

or claim adjudication

102 = Major medical adjustment

103 = Provider promotional discount (i.e.,

Senior citizen discount).

104 = Managed care withholding

105 = Tax withholding

Chronic Conditions Warehouse Virtual Research Data Center

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106 = Patient payment option/election

not in effect

107 = Claim/service denied because

the related or qualifying

claim/service was not paid or

identified on the claim

108 = Claim/service reduced because

rent/purchase guidelines were

not met

109 = Claim not covered by this

payer/contractor. You must send

the claim to the correct

payer/contractor

110 = Billing date predates service date

111 = Not covered unless the provider

accepts assignment

112 = Claim/service adjusted as not

furnished directly to the patient

and/or not documented

113 = Claim denied because

service/procedure was provided

outside the United States or as a

result of war

114 = Procedure/Product not

approved by the Food and Drug

Administration

115 = Claim/service adjusted as

procedure postponed or canceled

116 = Claim/service denied. The

advance indemnification notice

signed by the patient did not

comply with requirements

117 = Claim/service adjusted because

transportation is only covered to

the closest facility that can

provide the necessary care

118 = Charges reduced for ESRD

network support

119 = Benefit maximum for this time

period has been reached

120 = Patient is covered by a managed

care plan. INACTIVE

121 = Indemnification adjustment

122 = Psychiatric reduction

123 = Payer refund due to

overpayment. INACTIVE

124 = Payer refund amount — not our

patient. INACTIVE

125 = Claim/service adjusted due to a

submission/billing error(s)

126 = Deductible — Major Medical

127 = Coinsurance — Major Medical

128 = Newborn's services are covered

in the mother's allowance

129 = Claim denied — prior processing

information appears incorrect

130 = Paper claim submission fee

131 = Claim specific negotiated

discount

132 = Prearranged demonstration

project adjustment

133 = The disposition of this

claim/service is pending further

review

134 = Technical fees removed from

charges

135 = Claim denied. Interim bills

cannot be processed

136 = Claim adjusted. Plan procedures

of a prior payer were not

followed

Chronic Conditions Warehouse Virtual Research Data Center

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137 = Payment/Reduction for

Regulatory Surcharges,

Assessments, Allowances or

Health Related Taxes

138 = Claim/service denied. Appeal

procedures not followed, or time

limits not met

139 = Contracted funding agreement

— subscriber is employed by the

provider of services

140 = Patient/Insured health

identification number and name

do not match

141 = Claim adjustment because the

claim spans eligible and ineligible

periods of coverage

142 = Claim adjusted by the monthly

Medicaid patient liability amount

A0 = Patient refund amount

A1 = Claim denied charges

A2 = Contractual adjustment

A3 = Medicare Secondary Payer

liability met. INACTIVE

A4 = Medicare Claim PPS Capital Day

Outlier Amount

A5 = Medicare Claim PPS Capital Cost

Outlier Amount

A6 = Prior hospitalization or 30-day

transfer requirement not met

A7 = Presumptive Payment Adjustment

A8 = Claim denied; ungroupable DRG

B1 = Non-covered visits

B2 = Covered visits. INACTIVE

B3 = Covered charges. INACTIVE

B4 = Late filing penalty

B5 = Claim/service adjusted because

coverage/program guidelines were

not met or were exceeded

B6 = This service/procedure is adjusted

when performed/billed by this

type of provider, by this type of

facility, or by a provider of this

specialty

B7 = This provider was not

certified/eligible to be paid for this

procedure/service on this date of

service

B8 = Claim/service not

covered/reduced because

alternative services were available

and should have been utilized

B9 = Services not covered because the

patient is enrolled in a hospice

B10 = Allowed amount has been

reduced because a component of

the basic procedure/test was paid.

The beneficiary is not liable for

more than the charge limit for the

basic procedure/test

B11 = The claim/service has been

transferred to the proper

payer/processor for processing.

Claim/service not covered by this

payer/processor

B12 = Services not documented in

patients' medical records

B13 = Previously paid. Payment for this

claim/service may have been

provided in a previous payment

B14 = Claim/service denied because

only one visit or consultation per

physician per day is covered

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B15 = Claim/service adjusted because

this procedure/service is not paid

separately

B16 = Claim/service adjusted because

“New Patient” qualifications were

not met

B17 = Claim/service adjusted because

this service was not prescribed by

a physician, not prescribed prior

to delivery, the prescription is

incomplete, or the prescription is

not current

B18 = Claim/service denied because

this procedure code/modifier was

invalid on the date of service or

claim submission

B19 = Claim/service adjusted because of the

finding of a Review Organization.

INACTIVE

B20 = Charges adjusted because

procedure/service was partially or fully

furnished by another provider

B21 = The charges were reduced because the

service/care was partially furnished by

another physician. INACTIVE

B22 = This claim/service is adjusted based on

the diagnosis

B23 = Claim/service denied because this

provider has failed an aspect of a

proficiency testing program

W1 = Workers Compensation State Fee

Schedule Adjustment

COMMENT: This field is populated for those claims that are required to process through outpatient PPS PRICER

software. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland

providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical

Access Hospitals [CAH]); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of

bill with a condition code “07” and certain HCPCS. These claim types could have lines that are not

required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services

with dates of service 1/1/2002 and forward.

Valid beginning with NCH weekly process date 7/7/2000.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 383

REV_CNTR_ADJUST_GRP_CD

LABEL: Revenue Center Adjustment Group Code

DESCRIPTION: Claim adjustment group code used to categorize a payment adjustment for a claim or claim line. This

field is currently only populated for Direct Contracting (DC), Comprehensive Kidney Care Contracting

(CKCC) and Kidney Care First (KCF) model claims.

SHORT NAME: REV_CNTR_ADJUST_GRP_CD

LONG NAME: REV_CNTR_ADJUST_GRP_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES: CO = Contractual obligation

OA = Other adjustment

PR = Patient responsibility

COMMENT: This code set is an external code set maintained by X12 (www.x12.org/codes). This field is not

populated prior to 2021.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 384

REV_CNTR_ADJUST_RSN_CD

LABEL: Revenue Center Adjustment Reason Code

DESCRIPTION: Claim adjustment reason code used to describe why a claim or claim line was paid differently than

billed. This field is currently only populated for Direct Contracting (DC), Comprehensive Kidney Care

Contracting (CKCC) and Kidney Care First (KCF) model claims.

SHORT NAME: REV_CNTR_ADJUST_RSN_CD

LONG NAME: REV_CNTR_ADJUST_RSN_CD

TYPE: CHAR

LENGTH: 5

SOURCE: NCH

VALUES: This is not a comprehensive list of values; refer to website below for current values and descriptions:

94 = Processed in Excess of charges

119 = Benefit maximum for this time period or occurrence has been reached

132 = Prearranged demonstration project adjustment

COMMENT: This code set is an external code set maintained by X12 (www.x12.org/codes). This field is not

populated prior to 2021.

^ Back to TOC ^

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REV_CNTR_APC_HIPPS_CD

LABEL: Revenue Center APC or HIPPS Code

DESCRIPTION: This field contains one of two potential pieces of data; the Ambulatory Payment Classification (APC)

code or the Health Insurance prospective payment system (HIPPS) code, which corresponds with the

revenue center line for the claim.

The APC codes are used as the basis for payment for outpatient prospective payment (OPPS) service

(e.g., Part B institutional). Additional information regarding OPPS is available on the CMS website

(reference: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/HospitalOutpatientPPS/index.html).

Some Part A claim types (e.g., home health and SNF) use resource groupings, which are similar to case-

mix groups, as the basis for payment (e.g., HHRG, SNF RUGs).

For home health (HH) claims, when the revenue center code (variable called REV_CNTR) is 0023, the

HHRG is located in this field and is a HIPPS code. This field is only meaningful for a HH claim when CMS

determines the claim should be paid using a different HIPPS code than the one submitted by the

provider. When this happens, the revised HIPPS code (the one used for payment purposes) appears in

this field and the original HIPPS code submitted by the provider remains in the HCPCS_CD field.

Otherwise, this variable will always be null or have a value of “00000” for HH revenue center records.

The resource utilization group for the particular revenue center is located in the data field called the

APC or HIPPS code variable.

The APC is a four-byte field.

The HIPPS code is a five-byte field (such as 1AFKS).

SHORT NAME: APCHIPPS

LONG NAME: REV_CNTR_APC_HIPPS_CD

TYPE: CHAR

LENGTH: 5

SOURCE: NCH

VALUES: APC codes can be downloaded from the CMS website (reference:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/HospitalOutpatientPPS/passthrough_payment.html)

Examples of APC codes: 0002 = Fine needle Biopsy/Aspiration; 0812 = Carmustine injection

HIPPS codes can be downloaded from the CMS website Prospective Payment Systems page (reference:

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes.html).

1057 = Micromark Tissue Marker (eff. 1/2001)

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COMMENT: The APC field is populated for those claims that are required to process through outpatient PPS Pricer.

The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers,

Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access

Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with

a condition code “07” and certain HCPCS. These claim types could have lines that are not required to

price under OPPS rules so those lines would not have data in this field.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 387

REV_CNTR_BENE_PMT_AMT

LABEL: Revenue Center Payment Amount to Beneficiary

DESCRIPTION: The amount paid to the beneficiary for the services reported on the line item.

SHORT NAME: RBENEPMT

LONG NAME: REV_CNTR_BENE_PMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: This field is populated for those claims that are required to process through outpatient PPS PRICER

software. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland

providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical

Access Hospitals [CAH]); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of

bill with a condition code “07” and certain HCPCS. These claim types could have lines that are not

required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services

with dates of service 1/1/2002 and forward.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 388

REV_CNTR_BLOOD_DDCTBL_AMT

LABEL: Revenue Center Blood Deductible Amount

DESCRIPTION: This variable is the dollar amount the beneficiary is responsible for related to the deductible for blood

products that appear on the revenue center record.

A deductible amount applies to the first 3 pints of blood (or equivalent units; applies only to whole

blood or packed red cells — not platelets, fibrinogen, plasma, etc. which are considered biologicals).

However, blood processing is not subject to a deductible. Calculation of the deductible amount

considers both Part A and Part B claims combined. The blood deductible does not count toward

meeting the inpatient hospital deductible or any other applicable deductible and coinsurance amounts

for which the patient is responsible.

SHORT NAME: REVBLOOD

LONG NAME: REV_CNTR_BLOOD_DDCTBL_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: Costs to beneficiaries are described in detail on the Medicare.gov website. There is a CMS publication

called "Your Medicare Benefits", which explains the blood deductible.

This field is populated for those claims that are required to process through outpatient PPS PRICER

software. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland

providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical

Access Hospitals [CAH]); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of

bill with a condition code “07” and certain HCPCS. These claim types could have lines that are not

required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services

with dates of service 1/1/2002 and forward.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 389

REV_CNTR_CASH_DDCTBL_AMT

LABEL: Revenue Center Cash Deductible Amount

DESCRIPTION: This variable is the beneficiary’s liability under the annual Part B deductible for the revenue center

record. The Part B deductible applies to both institutional (e.g., HOP) and non-institutional (e.g.,

carrier and DME) services.

SHORT NAME: REVDCTBL

LONG NAME: REV_CNTR_CASH_DDCTBL_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: Costs to beneficiaries are described in detail on the Medicare.gov website. There is a CMS publication

called "Your Medicare Benefits", which explains the deductibles.

This field is populated for those claims that are required to process through outpatient PPS PRICER

software. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland

providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical

Access Hospitals [CAH]); 76X; 75X, and 34X if certain HCPCS are on the bill; and any outpatient type of

bill with a condition code “07” and certain HCPCS. These claim types could have lines that are not

required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services

with dates of service 1/2002 and forward.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 390

REV_CNTR_COINSRNC_WGE_ADJSTD_C

LABEL: Revenue Center Coinsurance/Wage Adjusted Coinsurance Amount

DESCRIPTION: This variable is the beneficiary’s liability for coinsurance for the revenue center record.

Beneficiaries only face coinsurance once they have satisfied Part B’s annual deductible, which applies

to both institutional (e.g., HOP) and non-institutional (e.g., carrier and DME) services.

For most Part B services, coinsurance equals 20 percent of the allowed amount.

The coinsurance amount is wage adjusted, based on the metropolitan statistical area (MSA) where the

provider is located.

SHORT NAME: WAGEADJ

LONG NAME: REV_CNTR_COINSRNC_WGE_ADJSTD_C

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: Medicare payments are described in detail in a series called the Medicare Learning Network (MLN)

“Payment System Fact Sheet Series” (reference the list of MLN publications at:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/html/medicare-payment-systems.html).

This field is populated for those claims that are required to process through outpatient PPS PRICER

software. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland

providers, Indian Health Providers and Critical Access Hospitals [CAH]); 76X; 75X and 34X if certain

HCPCS are on the bill; and any outpatient type of bill with a condition code “07” and certain HCPCS.

The above claim types could have lines that are not required to price under OPPS rules so those lines

would not have data in this field.

This field will have either a zero (for services for which coinsurance is not applicable), a regular

coinsurance amount (calculated on either charges or a fee schedule) or if subject to OP PPS the

national coinsurance amount will be wage adjusted. The wage adjusted coinsurance is based on the

MSA where the provider is located or assigned as a result of a reclassification.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 391

REV_CNTR_CRA_TPNIES_AMT

LABEL: Revenue Center Capital Related Assets Transitional Add-on Payment Amt New and Innovative Equip

DESCRIPTION: Revenue Center Capital Related Assets Adjustment (CRA) Transitional Add-on Payment Adjustment for

New and Innovative Equipment and Supplies (TPNIES) Amount.

This line level field represents the ESRD PPS add-on payment for capital-related assets (CRA). For

eligible CRAs that are home dialysis machines, ESRD facilities will be paid the CRA for TPNIES

SHORT NAME: REV_CNTR_CRA_TPNIES_AMT

LONG NAME: REV_CNTR_CRA_TPNIES_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XXXX

COMMENT: This only appears on outpatient claims. This field is not populated prior to 2021.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 392

REV_CNTR_DDCTBL_COINSRNC_CD

LABEL: Revenue Center Deductible Coinsurance Code

DESCRIPTION: Code indicating whether the revenue center charges are subject to deductible and/or coinsurance.

SHORT NAME: REVDEDCD

LONG NAME: REV_CNTR_DDCTBL_COINSRNC_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: 0 = Charges are subject to deductible and coinsurance

1 = Charges are not subject to deductible

2 = Charges are not subject to coinsurance

3 = Charges are not subject to deductible or coinsurance

4 = No charge or units associated with this revenue center code. (For multiple HCPCS per single

revenue center code)

For revenue center code 0001, the following MSP override values may be present:

M = Override code; EGHP (employer group health plan) services involved

N = Override code; non-EGHP services involved

X = Override code: MSP (Medicare is secondary payer) cost avoided

COMMENT: —

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 393

REV_CNTR_DSCNT_IND_CD

LABEL: Revenue Center Discount Indicator Code

DESCRIPTION: This code represents a factor that specifies the amount of any Ambulatory payment classification

(APC) discount. The discounting factor is applied to a line item with a service indicator (part of the

REV_CNTR_PMT_MTHD_IND_CD) of “T”. The flag is applicable when more than one significant

procedure is performed.

**If there is no discounting the factor will be 1.0.**

SHORT NAME: DSCNTIND

LONG NAME: REV_CNTR_DSCNT_IND_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: *DISCOUNTING FORMULAS*

1 = 1.0

2 = (1.0+D(U-1))/U

3 = T/U

4 = (1+D)/U

5 = D

6 = TD/U

7 = D(1+D)/U

8 = 2.0/U

D = Discounting fraction (currently 0.5)

U = Number of units

T = Terminated procedure discount (currently 0.5)

COMMENT: This field is populated for those claims that are required to process through outpatient prospective

payment system (PPS or OPPS) PRICER software. The type of bills (TOB) required to process through

are: 12X, 13X, 14X (except Maryland providers, Indian Health Providers, hospitals located in American

Samoa, Guam and Saipan and Critical Access Hospitals (CAH)); 76X; 75X and 34X if certain HCPCS are

on the bill; and any outpatient type of bill with a condition code “07” and certain HCPCS. These claim

types could have lines that are not required to price under OPPS rules so those lines would not have

data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services

with dates of service 1/1/2002 and forward.

It has been discovered that this field may be populated with data on claims with dates of service prior

to 7/2000 (implementation of Claim Line Expansion OPPS/HHPPS). The original understanding of the

new revenue center fields was that data would be populated on claims with dates of service 7/2000

and forward.

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Data has been found in claims with dates of service prior to 7/2000 because the Standard Systems

have processed any claim coming in 7/2000 and after, meeting the above criteria, through the

Outpatient Code Editor (OCE) regardless of the dates of service.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 395

REV_CNTR_DT

LABEL: Revenue Center Date

DESCRIPTION: This is the date of service for the revenue center record.

However, it is populated only for home health claims, hospice claims, and Part B institutional (HOP)

claims.

For home health claims, which are paid based on episodes that can last up to 60 days, this variable

indicates the dates for the individual visits.

SHORT NAME: REV_DT

LONG NAME: REV_CNTR_DT

TYPE: DATE

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: —

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 396

REV_CNTR_IDE_NDC_UPC_NUM

LABEL: Revenue Center IDE, NDC, or UPC Number

DESCRIPTION: This field may contain one of three types of identifiers: the National Drug Code (NDC), the Universal

Product Code (UPC), or the number assigned by the Food and Drug Administration (FDA) to an

investigational device (IDE) after the manufacturer has approval to conduct a clinical trial.

The IDEs will have a revenue center code “0624”.

SHORT NAME: IDENDC

LONG NAME: REV_CNTR_IDE_NDC_UPC_NUM

TYPE: CHAR

LENGTH: 24

SOURCE: NCH

VALUES: —

COMMENT: This field was renamed to eventually accommodate the National Drug Code (NDC) and the Universal

Product Code (UPC). This field could contain either of these 3 fields (there would never be an instance

where more than one would come in on a claim).

The size of this field was expanded to X(24) to accommodate either of the new fields (under version

“H” it was X(7).

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 397

REV_CNTR_NCVRD_CHRG_AMT

LABEL: Revenue Center Non-Covered Charge Amount

DESCRIPTION: The charge amount related to a revenue center code for services that are not covered by Medicare.

SHORT NAME: REV_NCVR

LONG NAME: REV_CNTR_NCVRD_CHRG_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: —

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 398

REV_CNTR_NDC_QTY

LABEL: Revenue Center National Drug Code (NDC) Quantity

DESCRIPTION: Effective with version “J,” the quantity dispensed for the drug reflected on the revenue center line

item.

SHORT NAME: REV_CNTR_NDC_QTY

LONG NAME: REV_CNTR_NDC_QTY

TYPE: NUM

LENGTH: 10

SOURCE: NCH

VALUES: —

COMMENT: The unit of measurement for the drug that was administered (e.g., grams, liters) is indicated in the

variable called REV_CNTR_NDC_QTY_QLFR_CD.

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Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 399

REV_CNTR_NDC_QTY_QLFR_CD

LABEL: Revenue Center NDC Quantity Qualifier Code

DESCRIPTION: Effective with version “J,” the code used to indicate the unit of measurement for the drug that was

administered.

SHORT NAME: REV_CNTR_NDC_QTY_QLFR_CD

LONG NAME: REV_CNTR_NDC_QTY_QLFR_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES: F2 = International Unit

GR = Gram

ML = Milliliter

UN = Unit

COMMENT: The quantity of the drug dispensed is indicated in the variable called REV_CNTR_NDC_QTY.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 400

REV_CNTR_OTAF_PMT_CD

LABEL: Revenue Center Obligation to Accept As Full (OTAF) Payment Code

DESCRIPTION: The code used to indicate that the provider was obligated to accept as full payment the amount

received from the primary (or secondary) payer.

SHORT NAME: OTAF_1

LONG NAME: REV_CNTR_OTAF_PMT_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: —

COMMENT: This field is populated for those claims that are required to process through outpatient PPS PRICER

software. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland

providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical

Access Hospitals [CAH]); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of

bill with a condition code “07” and certain HCPCS. These claim types could have lines that are not

required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services

with dates of service 1/1/2002 and forward.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 401

REV_CNTR_PACKG_IND_CD

LABEL: Revenue Center Packaging Indicator Code

DESCRIPTION: The code used to identify those services that are packaged/bundled with another service.

SHORT NAME: PACKGIND

LONG NAME: REV_CNTR_PACKG_IND_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: 0 = Not packaged

1 = Packaged service (service indicator N)

2 = Packaged as part of partial hospitalization per diem or daily mental health service per diem

3 = Artificial charges for surgical procedure (eff. 7/2004)

COMMENT: This field is populated for those claims that are required to process through outpatient PPS PRICER

software. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland

providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical

Access Hospitals [CAH]); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of

bill with a condition code “07” and certain HCPCS. These claim types could have lines that are not

required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services

with dates of service 1/1/2002 and forward.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 402

REV_CNTR_PMT_AMT_AMT

LABEL: Revenue Center (Medicare) Payment Amount

DESCRIPTION: To obtain the Medicare payment amount for the services reported on the revenue center record, it is

more accurate to use a different variable called the revenue center Medicare provider payment

amount (REV_CNTR_PRVDR_PMT_AMT).

For home health, use the claim-level Medicare payment amount (variable that is the total of all

revenue center records on the claim, which is called CLM_PMT_AMT), since each visit is not paid

separately.

SHORT NAME: REVPMT

LONG NAME: REV_CNTR_PMT_AMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: This field is populated for those claims that are required to process through outpatient PPS PRICER

software. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland

providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical

Access Hospitals [CAH]); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of

bill with a condition code “07” and certain HCPCS. These claim types could have lines that are not

required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services

with dates of service 1/1/2002 and forward.

^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 403

REV_CNTR_PMT_MTHD_IND_CD

LABEL: Revenue Center Payment Method Indicator Code

DESCRIPTION: The code used to identify how the service is priced for payment.

This field is made up of two pieces of data, 1st position being the status indicator and the 2nd position

being the payment indicator.

SHORT NAME: PMTMTHD

LONG NAME: REV_CNTR_PMT_MTHD_IND_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES:

0 = Unknown Value (but present in

data)

1 = Paid standard hospital OPPS

amount (status indicators J1, J2, R,

S, T, U, V)

2 = Services not paid under OPPS

Pricer; paid under fee schedule or

other payment system (status

indicators A, G, K)

3 = Not paid (status indicators Q1, Q2,

Q3, Q4, M, W, Y, E1, E2) or not

paid under OPPS (status indicators

B, C, Z)

4 = Paid at reasonable cost (status

indicator F and L)

5 = Paid standard amount for pass-

through drug or biological

(status indicator G)

6 = Payment based on charge

adjusted to cost (status indicator

7 = Additional payment for new drug

or new biological (status indicator

8 = Paid partial hospitalization per diem

(status indicator P)

9 = No additional payment, payment

included in line items with APCs (status

indicator N, or no HCPCS code and

certain revenue center codes, or HCPCS

codes G0176 (activity therapy), G0129

(occupational therapy) or G0177

(partial hospitalization program

services)

10 = Paid FQHC encounter payment

11 = Not paid or not included under FQHC

encounter payment

12 = No additional payment, included in

payment for FQHC encounter

13 = Paid FQHC encounter payment for

New patient or IPPE/AWV

14 = Grandfathered tribal FQHC encounter

payment

15 = FQHC IOP encounter payment

16 = Wrap-around payment for FQHCs that

contract with Medicare Advantage (MA)

organizations

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*********VALUES PRIOR TO 10/3/2005**************

**********Service Status Indicator**************

********** 1st position *****************

A = Services not paid under OPPS

C = Inpatient procedure

E = Non-covered items or services

F = Corneal tissue acquisition

G = Current drug or biological pass-

through

H = Device pass-through

J = New drug or new biological pass-

through

N = Packaged incidental service

P = Partial hospitalization services

S = Significant procedure not subject to multiple

procedure discounting

T = Significant procedure subject to

multiple procedure discounting

V = Medical visit to clinic or emergency

department

X = Ancillary service

**********Payment Indicator**************

********** 2nd position *****************

1 = Paid standard hospital OPPS

amount (service indicators S,T,V,X)

2 = Services not paid under OPPS

(service indicator A, or no HCPCS

code and not certain revenue

center codes)

3 = Not paid (service indicators C and

4 = Acquisition cost paid (service

indicator F)

5 = Additional payment for current

drug or biological (service indicator

6 = Additional payment for device (service

indicator H)

7 = Additional payment for new drug or new

biological (service indicator J)

8 = Paid partial hospitalization per diem

(service indicator P)

9 = No additional payment, payment

included in line items with APCs (service

indicator N, or no HCPCS code and certain

revenue center codes, or HCPCS codes

Q0082 (activity therapy), G0129

(occupational therapy) or G0172 (partial

hospitalization training)

COMMENT: Prior to 10/2005, this variable contained the valid values for both the payment indicator and status

indicator. Effective 10/2005, only the payment indicator codes remain in this table and the status

indicator is housed in a new field named: REV_CNTR_STUS_IND_CD (with the corresponding values in

the new table: REV_CNTR_STUS_IND_TB). Both the payment indicator and status indicator values have

been expanded to 2-btyes.

This field is populated for those claims that are required to process through outpatient PPS PRICER

software. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland

providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical

Access Hospitals [CAH]); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of

bill with a condition code “07” and certain HCPCS. These claim types could have lines that are not

required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services

with dates of service 1/1/2002 and forward. ^ Back to TOC ^

Chronic Conditions Warehouse Virtual Research Data Center

CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 405

REV_CNTR_PRCNG_IND_CD

LABEL: Revenue Center Pricing Indicator Code

DESCRIPTION: The code used to identify if there was a deviation from the standard method of calculating payment

amount.

SHORT NAME: REV_CNTR_PRCNG_IND_CD

LONG NAME: REV_CNTR_PRCNG_IND_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES:

A = A valid HCPCS code not subject to a

fee schedule payment.

Reimbursement is calculated on

provider submitted charges.

B = A valid HCPCS code subject to the

fee schedule payment. for the

provider billed charges. NOTE:

There is an exception for Critical

Access Hospitals (provider numbers

XX1300–XX1399) with

reimbursement method “J” (all-

inclusive method) and dates of

service on or after 7/1/2001. In

these situations, reimbursement for

professional services (revenue

codes 96X, 97X, 98X) is always at

the fee schedule amount of logic is

not applicable.

C = Unlisted Rehabilitation carrier

Priced HCPCS

D = A valid radiology HCPCS code

subject to the Radiology Pricer and

the rate is reflected as zeroes on

the HCPCS file and cost report. The

Radiology Pricer treats this HCPCS

as a non-covered service.

Reimbursement is calculated on

provider submitted charges.

E = A valid ASC HCPCS code subject to the ASC

Pricer. The rate is reflected as zeroes on

the HCPCS file. The ASC Pricer determines

the ASC payment rate and is reported on

the cost report.

F = A valid ESRD HCPCS code subject to the

parameter rate. Reimbursement is the

lesser of provider submitted charges or the

fee schedule amount for non-dialysis

HCPCS. Reimbursement is calculated on

the provider file rates for dialysis HCPCS.

NOTE: The ESRD Pricing Indicator is used

when processing the ESRD claim. The non-

ESRD pricing indicator is used only for

inpatient claims as follows: valid

Hemophilia HCPCS for inpatient claim only

and code is summed to parameter rate.

G = A valid HCPCS, code is subject to a fee

schedule, but the rate is no longer present

on the HCPCS file. Reimbursement is

calculated on provider submitted charges.

H = A valid DME HCPCS, code is subject to a

fee schedule. The rates are reflected under

the DME segment. Reimbursement is

calculated either on a fee schedule,

provider submitted charges or the lesser of

provider submitted, or the fee schedule

depending on the category of DME.

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I = A valid DME category 5 HCPCS,

HCPCS is not found on the DME

history record, but a match was

found on HIC, category and generic

code. Claim must be reviewed by

Medical Review before payment

can be calculated.

J = A valid DME HCPCS, no DME history

is present, and a prescription is

required before delivery. Claim

must be reviewed by Medical

Review.

K = A valid DME HCPCS, prescribed has

been reviewed, and fee schedule

payment is approved as

prescription was present before

delivery.

L = A valid TENS HCPCS, rental period is

six months or greater and must be

reviewed by Medical Review. This

code will be automatically set by

the system.

M = A valid TENS HCPCS, Medical

Review has approved the rental

charge in excess of five months.

This must be set by Medical

Review. This must be set by

Medical Review when approved for

payment.

N = Paid based on the fee amount for

non ESRD TOB's. NOTE: Fee amount

is paid regardless of charges.

Q = Manual pricing

R = A valid radiology HCPCS code and is

subject to APC. The rate is reported

on the cost report. Reimbursement is

calculated on provider submitted

charges.

S = Valid influenza/PPV HCPCS. A fee

amount is not applicable. The amount

payable is present in the covered

charge field. This amount is not

subject to the coinsurance and

deductible. This charge is subject to

the provider's reimbursement rate.

T = Valid HCPCS. A fee amount is present.

The amount payable should be the

lower of the billed charge or fee

amount. The system should compute

the fee amount by multiplying the

covered units times the rate. The fee

amount is not subject to coinsurance

and deductible or provider's

reimbursement rate.

U = Valid ambulance HCPCS. A fee

amount is present. The amount

payable is a blended amount based

on a percentage of the fee schedule

and a percentage of the reasonable

cost. The fee amount is subject to

coinsurance and deductible.

X = Unclassified drug as subject to

manual pricing.

COMMENT: This field is populated for those claims that are required to process through the outpatient PPS PRICER

software. The type of bills (TOB) required to process through are: 12X,13X, 14X (except Maryland

providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical

Access Hospitals [CAH]); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of

bill with a condition code “07” and certain HCPCS. These claim types could have lines that are not

required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services

with dates of service 1/1/2002 and forward.

It has been discovered that this field may be populated with data on claims with dates of service prior

to 7/2000 (implementation of Claim Line Expansion OPPS/HHPPS). The original understanding of the

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new revenue center fields was that data would be populated on claims with dates of service 7/2000

and forward. Data has been found in claims with dates of service prior to 7/2000 because the

Standard Systems have processed any claim coming in 7/2000 and after, meeting the above criteria,

through the Outpatient Code Editor (OCE) regardless of the dates of service.

VALUES D, U and T REPRESENT THE FOLLOWING:

• D = Discounting fraction (currently 0.5)

• U = Number of units

• T = Terminated procedure discount (currently 0.5)

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REV_CNTR_PRVDR_PMT_AMT

LABEL: Revenue Center (Medicare) Provider Payment Amount

DESCRIPTION: The amount Medicare paid for the services reported on the revenue center record.

This field is rarely populated for Part A claims due to per-diem or DRG payments; the claim payment

amounts should be used instead.

For Hospital outpatient services (also called Institutional outpatient claims, which consist of claim type

[variable called NCH_CLM_TYPE_CD] = 40), this variable can be summed across all revenue center lines

for the claim to obtain the total Medicare claim payment amount.

SHORT NAME: RPRVDPMT

LONG NAME: REV_CNTR_PRVDR_PMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: This field is populated for those claims that are required to process through outpatient PPS PRICER

software. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland

providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical

Access Hospitals [CAH]); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of

bill with a condition code “07” and certain HCPCS. These claim types could have lines that are not

required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services

with dates of service 1/1/2002 and forward.

Additional information regarding claim versus revenue-line level payments can be found in a CCW

Technical Guidance document entitled: "Getting Started with Medicare Administrative Data."

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REV_CNTR_PTNT_RSPNSBLTY_PMT

LABEL: Revenue Center Patient Responsibility Payment Amount

DESCRIPTION: The amount paid by the beneficiary to the provider for the line-item service.

SHORT NAME: PTNTRESP

LONG NAME: REV_CNTR_PTNT_RSPNSBLTY_PMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: This field is populated for those claims that are required to process through outpatient PPS software.

The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland providers,

Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical Access

Hospitals [CAH]); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of bill with

a condition code “07” and certain HCPCS. These claim types could have lines that are not required to

price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services

with dates of service 1/1/2002 and forward.

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REV_CNTR_RATE_AMT

LABEL: Revenue Center Rate Amount

DESCRIPTION: Charges relating to unit cost associated with the revenue center code.

SHORT NAME: REV_RATE

LONG NAME: REV_CNTR_RATE_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: For SNF PPS claims (when revenue center code equals “0022”), CMS has developed a SNF PRICER to

compute the rate based on the provider supplied coding for the MDS RUGS III group and assessment

type (HIPPS code, stored in revenue center HCPCS code field).

For OP PPS claims, CMS has developed a PRICER to compute the rate based on the Ambulatory

Payment Classification (APC), discount factor, units of service and the wage index.

Under HH PPS (when revenue center code equals “0023”), CMS has developed a HHA PRICER to

compute the rate. On the RAP, the rate is determined using the case mix weight associated with the

HIPPS code, adjusting it for the wage index for the beneficiary's site of service, then multiplying the

result by 60% or 50%, depending on whether or not the RAP is for a first episode.

On the final claim, the HIPPS code could change the payment if the therapy threshold is not met, or

partial episode payment (PEP) adjustment or a significant change in condition (SCIC) adjustment.

In cases of SCICs, there will be more than one “0023” revenue center line, each representing the

payment made at each case-mix level.

For IRF PPS claims (when revenue center code equals “0024”), CMS has developed a PRICER to

compute the rate based on the HIPPS/CMG (HIPPS code, stored in revenue center HCPCS code field).

Exception (encounter data only): If plan (e.g., MCO) does not know the actual rate for the

accommodations, $1 will be reported in the field.

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REV_CNTR_RDCD_COINSRNC_AMT

LABEL: Revenue Center Reduced Coinsurance Amount

DESCRIPTION: For all services subject to outpatient prospective payment system (PPS or OPPS), the amount of

coinsurance applicable to the line for a particular service (as indicated by the HCPCS code) for which

the provider has elected to reduce the coinsurance amount.

SHORT NAME: RDCDCOIN

LONG NAME: REV_CNTR_RDCD_COINSRNC_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: This field is populated for those claims that are required to process through outpatient PPS PRICER

software. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland

providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical

Access Hospitals [CAH]); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of

bill with a condition code “07” and certain HCPCS.

These claim types could have lines that are not required to price under OPPS rules so those lines

would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services

with dates of service 1/1/2002 and forward.

The reduced coinsurance amount cannot be lower than 20% of the payment rate for the APC line.

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REV_CNTR_RP_IND_CD

LABEL: Revenue Center Representative Payee (RP) Indicator Code

DESCRIPTION: Revenue Center Representative Payee (RP) Indicator Code

SHORT NAME: REV_CNTR_RP_IND_CD

LONG NAME: REV_CNTR_RP_IND_CD

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: R = bypass representative payee

COMMENT: This field is used to designate by-passing of the prior authorization processing for claims with a

representative payee when an “R” is present in the field.

This field was new in April 2016.

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REV_CNTR_STUS_IND_CD

LABEL: Revenue Center Status Indicator Code

DESCRIPTION: This variable indicates how the service listed on the revenue center record was priced for payment

purposes.

The revenue center status indicator code is most useful with outpatient hospital claims, where

multiple methods may be used to determine the payment amount for the various revenue center

records on the claim (for example, some lines may be bundled into an APC and paid under the

outpatient PPS, while other lines may be paid under other fee schedules).

SHORT NAME: REVSTIND

LONG NAME: REV_CNTR_STUS_IND_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES:

A = Services not paid under OPPS; paid

under fee schedule or other

payment system (Includes

Unclassified drugs and biologicals

reportable under HCPCS code

C9399)

B = Non-allowed item or service for

OPPS; may be paid under a

different bill type (e.g., CORF)

C = Inpatient procedure

E = Non-allowed item or service

(discontinued 01/01/2017)

E1 = Non-allowed item or service

E2 = Items and services for which

pricing information and claims

data are not available

F = Corneal tissue acquisition, certain

CRNA services

G = Drug/biological pass-through

H = Pass-through device categories

I = Inpatient Rehabilitation Facility (IRF) PPS -

Submitted and priced HIPPS/CMG codes are

different, changed by IRF PPS PRICER

NOTE: The priced HIPPS/CMG code is displayed on the

revenue code 0024 line in the PAY/HCPC/APC CD field

when different from the submitted HIPPS/CMG code

displayed in the HCPC field

J = New drug or new biological pass-

through (discontinued 04/01/2002

and replaced by status indicator G

for all drugs/biologicals)

J1 = Hospital Part B services paid

through a comprehensive APC;

eff. 01/2015)

J2 = Hospital Part B services that may

be paid through a comprehensive

APC

K = Non pass-through drugs and non-

implantable biologicals, including

therapeutic radiopharmaceuticals)

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L = Influenza Vaccine; Pneumococcal

Pneumonia Vaccine; Hepatitis B

Vaccines; Covid-19 Vaccine;

Monoclonal Antibody Therapy

Product

M = Service not billable to fiscal

intermediary [now a MAC] (not

paid under OPPS); For home

health - Medical Review changes

a HIPPS code

N = Items and Services packaged into

APC rates

P = For Outpatient claims - Partial

Hospitalization; For home health -

Claim contains less than 10

therapy revenue codes and no

medical review intervention

Q = Packaged services subject to

separate payment based on

payment criteria (discontinued

01/01/2009 and replaced by

status indicators Q1, Q2, Q3, Q4)

Q1 STV-Packaged codes

Q2 = T-Packaged codes

Q3 = Codes that may be paid through

a composite APC- (eff. 2009)

Q4 = Conditionally packaged

laboratory services

R = Blood and blood products

S = Procedure or service, not

discounted when multiple

T = Procedure or service, multiple

reduction applies

U = Brachytherapy sources

V = Clinic or emergency department

visit

W = Invalid HCPCS or invalid revenue

code with blank HCPCS

X = Ancillary service (terminated)

Y = Non-implantable DME (e.g.,

therapeutic shoes)

Z = Valid revenue with blank HCPCS

and no other status indicator

assigned

COMMENT: This 2-byte indicator was added 10/2005 due to an expansion of a field that currently exist on the

revenue center trailer. The status indicator is currently the 1st position of the Revenue Center

Payment Method Indicator Code. The payment method indicator code is being split into two 2-byte

fields (payment indicator and status indicator). The expanded payment indicator will continue to be

stored in the existing payment method indicator field. The split of the current payment method

indicator field is due to the expansion of both pieces of data from 1-byte to 2-bytes.

This field is populated for those claims that are required to process through outpatient PPS PRICER

software. The type of bills (TOB) required to process through are: 12X, 13X, 14X (except Maryland

providers, Indian Health Providers, hospitals located in American Samoa, Guam and Saipan and Critical

Access Hospitals [CAH]); 76X; 75X and 34X if certain HCPCS are on the bill; and any outpatient type of

bill with a condition code “07” and certain HCPCS. These claim types could have lines that are not

required to price under OPPS rules so those lines would not have data in this field.

Additional exception: Virgin Island hospitals and hospitals that furnish only inpatient Part B services.

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 415

REV_CNTR_RA_RMRK_CD

LABEL: Revenue Center Remittance Advice Remark Code

DESCRIPTION: Claim Remittance Advice Remark Code used to provide an additional explanation for an adjustment

already described by a claim adjustment reason code (CARC) for a claim or claim line. It is also used to

communicate information about remittance processing. This field is currently only populated for

Direct Contracting (DC), Comprehensive Kidney Care Contracting (CKCC) and Kidney Care First (KCF)

model claims.

SHORT NAME: REV_CNTR_RA_RMRK_CD

LONG NAME: REV_CNTR_RA_RMRK_CD

TYPE: CHAR

LENGTH: 5

SOURCE: NCH

VALUES: N83 = No appeal rights. Adjudicative decision based on the provisions of a demonstration project.

COMMENT: This code set is an external code set maintained by X12 (www.x12.org/codes). This field is not

populated prior to 2021.

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REV_CNTR_THRPY_RDCTN_AMT

LABEL: Revenue Center Therapy Reduction Amount

DESCRIPTION: This line level field is used to represent the 15% reduction amount for physical therapy assistant (PTA)

and occupational therapy assistant (OTA) services when modifiers CO or CQ are present.

SHORT NAME: REV_CNTR_THRPY_RDCTN_AMT

LONG NAME: REV_CNTR_THRPY_RDCTN_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: X.XX

COMMENT: Applies to types of bill (TOB)s; 13x, 22x, 23x, 34x, 74x, and 75x. This only appears on outpatient claims.

This field is not populated prior to 2021.

The TOB is the concatenation of two variables:

Facility type (CLM_FAC_TYPE_CD)

Service classification type (CLM_SRVC_CLSFCTN_TYPE_CD).

Effective January 3, 2023, this field will include the Rural Emergency Hospital (REH) 5% payment

increase. Applies to claims processed by the outpatient prospective payment system (OPPS), identified

by provider type of “24K”, CLM_OP_PPS_IND = 2, and TOBs 13X and 14X.

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REV_CNTR_TOT_CHRG_AMT

LABEL: Revenue Center Total Charge Amount

DESCRIPTION: The total charges (covered and non-covered) for all accommodations and services (related to the

revenue code) for a billing period before reduction for the deductible and coinsurance amounts and

before an adjustment for the cost of services provided.

SHORT NAME: REV_CHRG

LONG NAME: REV_CNTR_TOT_CHRG_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: For accommodation revenue center total charges must equal the rate times units (days).

EXCEPTIONS:

1. For SNF RUGS demo claims only (9000 series revenue center codes), this field contains SNF

customary accommodation charge, (i.e., charges related to the accommodation revenue center

code that would have been applicable if the provider had not been participating in the demo).

2. For SNF PPS (non-demo claims), when revenue center code = “0022”, the total charges will be

zero.

3. For home health PPS (RAPs), when revenue center code = “0023”, the total charges will equal the

dollar amount for the “0023” line.

4. For home health PPS (final claim), when revenue center code = “0023”, the total charges will be

the sum of the revenue center code lines (other than “0023”).

5. For inpatient Rehabilitation Facility (IRF) PPS, when the revenue center code = “0024”, the total

charges will be zero. For accommodation revenue codes (010X–021X), total charges must equal

the rate times the units.

6. For encounter data, if the plan (e.g., MCO) does not know the actual charges for the

accommodations the total charges will be $1 (rate) times units (days).

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REV_CNTR_UNIT_CNT

LABEL: Revenue Center Unit Count

DESCRIPTION: A quantitative measure (unit) of the number of times the service or procedure being reported was

performed according to the revenue center/HCPCS code definition as described on an institutional

claim.

Depending on type of service, units are measured by number of covered days in a particular

accommodation, pints of blood, emergency room visits, clinic visits, dialysis treatments (sessions or

days), outpatient therapy visits, and outpatient clinical diagnostic laboratory tests.

SHORT NAME: REV_UNIT

LONG NAME: REV_CNTR_UNIT_CNT

TYPE: NUM

LENGTH: 8

SOURCE: NCH

VALUES: —

COMMENT: When revenue center code = “0022” (SNF PPS) the unit count will reflect the number of covered days

for each HIPPS code and, if applicable, the number of visits for each rehab therapy code.

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RFR_PHYSN_NPI

LABEL: Claim Referring Physician NPI Number

DESCRIPTION: The national provider identifier (NPI) number assigned to uniquely identify the referring physician.

SHORT NAME: RFR_PHYSN_NPI*

LONG NAME: RFR_PHYSN_NPI

TYPE: CHAR

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: * The short SAS name is RFR_NPI in the carrier and DME files

NPIs replaced UPINs as the standard provider identifiers beginning in 2007. The UPIN is almost never

populated after 2009.

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RFR_PHYSN_SPCLTY_CD

LABEL: Claim Referring Physician Specialty Code

DESCRIPTION: The code used to identify the CMS specialty code of the referring physician/practitioner.

SHORT NAME: RFR_PHYSN_SPCLTY_CD

LONG NAME: RFR_PHYSN_SPCLTY_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES:

00 = carrier wide

01 = General practice

02 = General surgery

03 = Allergy/immunology

04 = Otolaryngology

05 = Anesthesiology

06 = Cardiology

07 = Dermatology

08 = Family practice

09 = Interventional Pain Management

(IPM) (eff. 4/1/2003)

10 = Gastroenterology

11 = Internal medicine

12 = Osteopathic manipulative

medicine

13 = Neurology

14 = Neurosurgery

15 = Speech/language pathologist in

private practice

16 = Obstetrics/gynecology

17 = Hospice and Palliative Care

18 = Ophthalmology

19 = Oral surgery (dentists only)

20 = Orthopedic surgery

21 = Cardiac Electrophysiology

22 = Pathology

23 = Sports medicine

24 = Plastic and reconstructive surgery

25 = Physical medicine and

rehabilitation

26 = Psychiatry

27 = Geriatric Psychiatry

28 = Colorectal surgery (formerly

proctology)

29 = Pulmonary disease

30 = Diagnostic radiology

31 = Intensive cardiac rehabilitation

32 = Anesthesiologist Assistant (eff.

4/1/2003 — previously grouped

with Certified Registered Nurse

Anesthetists (CRNA))

33 = Thoracic surgery

34 = Urology

35 = Chiropractic

36 = Nuclear medicine

37 = Pediatric medicine

38 = Geriatric medicine

39 = Nephrology

40 = Hand surgery

41 = Optometry

42 = Certified nurse midwife

43 = Certified Registered Nurse

Anesthetist (CRNA)

(Anesthesiologist Assistants were

removed from this specialty

4/1/2003)

44 = Infectious disease

45 = Mammography screening center

46 = Endocrinology

47 = Independent Diagnostic Testing

Facility (IDTF)

48 = Podiatry

49 = Ambulatory surgical center

(formerly miscellaneous)

50 = Nurse practitioner

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51 = Medical supply company with

certified orthotist (certified by

American Board for Certification

in Prosthetics and Orthotics)

52 = Medical supply company with

certified prosthetist (certified by

American Board for Certification

in Prosthetics and Orthotics)

53 = Medical supply company with

certified prosthetist-orthotist

(certified by American Board for

Certification in Prosthetics and

Orthotics)

54 = Medical supply company for

DMERC (and not included in 51–

53)

55 = Individual certified orthotic

personnel certified by an

accrediting organization

56 = Individual certified prosthetic

personnel certified by an

accrediting organization

57 = Individual certified prosthetic-

orthotic personnel certified by an

accrediting organization

58 = Medical supply company with

registered pharmacist

59 = Ambulance service (private)

60 = Public health or welfare agencies

(federal, state, and local)

61 = Voluntary health or charitable

agencies (e.g., National Cancer

Society, National Heart

Association, Catholic Charities)

62 = Psychologist (billing

independently)

63 = Portable X-ray supplier (billing

independently)

64 = Audiologist (billing independently)

65 = Physical therapist in private

practice

66 = Rheumatology

67 = Occupational therapist in private

practice

68 = Clinical psychologist

69 = Clinical laboratory (billing

independently)

70 = Single or Multispecialty clinic or

group practice (PA Group)

71 = Registered Dietician/Nutrition

Professional (eff. 1/1/2002)

72 = Pain Management (eff. 1/1/2002)

73 = Mass Immunization Roster Biller

74 = Radiation Therapy Centers (prior

to 4/2003 this included

Independent Diagnostic Testing

Facilities (IDTF)

75 = Slide Preparation Facilities (added

to differentiate them from

Independent Diagnostic Testing

Facilities (IDTFs — eff. 4/1/2003)

76 = Peripheral vascular disease

77 = Vascular surgery

78 = Cardiac surgery

79 = Addiction medicine

80 = Licensed clinical social worker

81 = Critical care (intensivists)

82 = Hematology

83 = Hematology/oncology

84 = Preventive medicine

85 = Maxillofacial surgery

86 = Neuropsychiatry

87 = All other suppliers (e.g., drug

stores)

88 = Unknown provider

89 = Certified clinical nurse specialist

90 = Medical oncology

91 = Surgical oncology

92 = Radiation oncology

93 = Emergency medicine

94 = Interventional radiology

95 = Competitive Acquisition Program

(CAP) Vendor (eff. 07/2001/2006).

Prior to 07/2001/2006, known as

Independent physiological

laboratory

96 = Optician

97 = Physician assistant

98 = Gynecological/oncology

99 = Unknown physician specialty

A0 = Hospital (DMERCs only)

A1 = Skilled nursing facility (DMERCs

only)

A2 = Intermediate care nursing facility

(DMERCs only)

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A3 = Nursing facility, other (DMERCs

only)

A4 = Home health agency (DMERCs

only)

A5 = Pharmacy (DMERC)

A6 = Medical supply company with

respiratory therapist (DMERCs

only)

A7 = Department store (DMERC)

A8 = Grocery store (DMERC)

A9 = Indian Health Service (IHS), tribe

and tribal organizations (non-

hospital or non-hospital-based

facilities, eff. 1/2005)

B1 = Supplier of oxygen and/or oxygen

related equipment (eff. 10/2007)

B2 = Pedorthic Personnel (eff.

10/2007)

B3 = Medical Supply Company with

pedorthic personnel (eff.

10/2007)

B4 = Does not meet definition of

health care provider (e.g.,

Rehabilitation agency, organ

procurement organizations,

histocompatibility labs) (eff.

10/2/2007)

B5 = Ocularist

C0 = Sleep medicine

C1 = Centralized flu

C2 = Indirect payment procedure

C3 = Interventional cardiology

C5 = Dentist (eff. 7/2016)

C6 = Hospitalist

C7 = Advanced heart failure and transplant

cardiology

C8 = Medical toxicology

C9 = Hematopoietic cell transplantation

and cellular therapy

D3 = Medical genetics and genomics

D4 = Undersea and Hyperbaric Medicine

D5 = Opioid Treatment Program (eff.

1/2020)

D7 = Micrographic Dermatologic Surgery

(MDS) (eff. 10/2020)

D8 = Adult Congenital Heart Disease

E1 = Marriage and Family Therapists

E2 = Mental Health Counselors

E3 = Dental Anesthesiology

E4 = Dental Public Health

E5 = Endodontics

E6 = Oral and Maxillofacial Pathology

E7 = Oral and Maxillofacial Radiology

E9 = Oral Medicine

F1 = Orofacial Pain

F2 = Orthodontics and Dentofacial Orthopedics

F3 = Pediatric Dentistry

F4 = Periodontics

F5 = Prosthodontics

COMMENT: —

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RFR_PHYSN_UPIN

LABEL: Carrier/DMERC Claim Ordering Physician UPIN Number

DESCRIPTION: The unique physician identification number (UPIN) of the physician who referred the beneficiary or

the physician who ordered the Part B services or durable medical equipment (DME).

NPIs replaced UPINs as the standard provider identifiers beginning in 2007. The UPIN is almost never

populated after 2009.

SHORT NAME: RFR_UPIN

LONG NAME: RFR_PHYSN_UPIN

TYPE: CHAR

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: —

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RLT_COND_CD_SEQ

LABEL: Claim Related Condition Code Sequence

DESCRIPTION: The sequence number of the claim related condition code (variable called CLM_RLT_COND_CD).

SHORT NAME: RLTCNDSQ

LONG NAME: RLT_COND_CD_SEQ

TYPE: CHAR

LENGTH: 3

SOURCE: CCW

VALUES: —

COMMENT: —

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RLT_OCRNC_CD_SEQ

LABEL: Claim Related Occurrence Code Sequence

DESCRIPTION: The sequence number of the claim related occurrence code (variable called CLM_RLT_OCRNC_CD).

SHORT NAME: RLTOCRSQ

LONG NAME: RLT_OCRNC_CD_SEQ

TYPE: CHAR

LENGTH: 3

SOURCE: CCW

VALUES: —

COMMENT: —

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RLT_SPAN_CD_SEQ

LABEL: Claim Related Span Code Sequence

DESCRIPTION: The sequence number of the related span code (variable called CLM_SPAN_CD).

SHORT NAME: RLTSPNSQ

LONG NAME: RLT_SPAN_CD_SEQ

TYPE: CHAR

LENGTH: 2

SOURCE: CCW

VALUES: —

COMMENT: —

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CODEBOOK: Medicare FFS Claims (version L) │ August 2024 │ V 1.12 427

RLT_VAL_CD_SEQ

LABEL: Claim Related Value Code Sequence

DESCRIPTION: The sequence number of the related claim value code (variable called CLM_VAL_CD).

SHORT NAME: RLTVALSQ

LONG NAME: RLT_VAL_CD_SEQ

TYPE: CHAR

LENGTH: 3

SOURCE: CCW

VALUES: —

COMMENT: —

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RNDRNG_PHYSN_NPI

LABEL: Rendering Physician NPI

DESCRIPTION: This variable is the National Provider Identifier (NPI) for the physician who rendered the services.

NPIs replaced UPINs as the standard provider identifiers beginning in 2007. The UPIN is almost never

populated after 2009.

SHORT NAME: RNDRNG_PHYSN_NPI

LONG NAME: RNDRNG_PHYSN_NPI

TYPE: CHAR

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: This field appears on both the revenue center and base claim files.

CMS has determined that dual provider identifiers (old legacy numbers and new NPI) must be

available in the NCH. After the 5/2007 NPI implementation, the standard system maintainers will add

the legacy number to the claim when it is adjudicated. We will continue to receive the OSCAR provider

number and any currently issued UPINs. Effective May 2007, no new UPINs (legacy numbers) will be

generated for new physicians (Part B and outpatient claims), so there will only be NPIs sent into the

NCH for those physicians.

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RNDRNG_PHYSN_SPCLTY_CD

LABEL: Claim or Revenue Center Rendering Physician Specialty Code

DESCRIPTION: The code used to identify the CMS specialty code of the rendering physician/practitioner.

SHORT NAME: RNDRNG_PHYSN_SPCLTY_CD

LONG NAME: RNDRNG_PHYSN_SPCLTY_CD

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES:

00 = Carrier wide

01 = General practice

02 = General surgery

03 = Allergy/immunology

04 = Otolaryngology

05 = Anesthesiology

06 = Cardiology

07 = Dermatology

08 = Family practice

09 = Interventional Pain Management

(IPM) (eff. 4/1/2003)

10 = Gastroenterology

11 = Internal medicine

12 = Osteopathic manipulative

medicine

13 = Neurology

14 = Neurosurgery

15 = Speech/language pathologist in

private practice

16 = Obstetrics/gynecology

17 = Hospice and Palliative Care

18 = Ophthalmology

19 = Oral surgery (dentists only)

20 = Orthopedic surgery

21 = Cardiac Electrophysiology

22 = Pathology

23 = Sports medicine

24 = Plastic and reconstructive surgery

25 = Physical medicine and

rehabilitation

26 = Psychiatry

27 = Geriatric Psychiatry

28 = Colorectal surgery (formerly

proctology)

29 = Pulmonary disease

30 = Diagnostic radiology

31 = Intensive cardiac rehabilitation

32 = Anesthesiologist Assistant (eff.

4/1/2003 — previously grouped

with Certified Registered Nurse G

33 = Thoracic surgery

34 = Urology

35 = Chiropractic

36 = Nuclear medicine

37 = Pediatric medicine

38 = Geriatric medicine

39 = Nephrology

40 = Hand surgery

41 = Optometry

42 = Certified nurse midwife

43 = Certified Registered Nurse

Anesthetist (CRNA)

(Anesthesiologist Assistants were

removed from this specialty

4/1/2003)

44 = Infectious disease

45 = Mammography screening center

46 = Endocrinology

47 = Independent Diagnostic Testing

Facility (IDTF)

48 = Podiatry

49 = Ambulatory surgical center

(formerly miscellaneous)

50 = Nurse practitioner

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51 = Medical supply company with

certified orthotist (certified by

American Board for Certification

in Prosthetics and Orthotics)

52 = Medical supply company with

certified prosthetist (certified by

American Board for Certification

in Prosthetics and Orthotics)

53 = Medical supply company with

certified prosthetist-orthotist

(certified by American Board for

Certification in Prosthetics and

Orthotics)

54 = Medical supply company for

DMERC (and not included in 51–

53)

55 = Individual certified orthotic

personnel certified by an

accrediting organization

56 = Individual certified prosthetic

personnel certified by an

accrediting organization

57 = Individual certified prosthetic-

orthotic personnel certified by an

accrediting organization

58 = Medical supply company with

registered pharmacist

59 = Ambulance service (private)

60 = Public health or welfare agencies

(federal, state, and local)

61 = Voluntary health or charitable

agencies (e.g., National Cancer

Society, National Heart

Association, Catholic Charities)

62 = Psychologist (billing

independently)

63 = Portable X-ray supplier (billing

independently)

64 = Audiologist (billing independently)

65 = Physical therapist in private

practice

66 = Rheumatology

67 = Occupational therapist in private

practice

68 = Clinical psychologist

69 = Clinical laboratory (billing

independently)

70 = Single or Multispecialty clinic or

group practice (PA Group)

71 = Registered Dietician/Nutrition

Professional (eff. 1/1/2002)

72 = Pain Management (eff. 1/1/2002)

73 = Mass Immunization Roster Biller

74 = Radiation Therapy Centers (prior

to 4/2003 this included

Independent Diagnostic Testing

Facilities (IDTF)

75 = Slide Preparation Facilities (added

to differentiate them from

Independent Diagnostic Testing

Facilities (IDTFs — eff. 4/1/2003)

76 = Peripheral vascular disease

77 = Vascular surgery

78 = Cardiac surgery

79 = Addiction medicine

80 = Licensed clinical social worker

81 = Critical care (intensivists)

82 = Hematology

83 = Hematology/oncology

84 = Preventive medicine

85 = Maxillofacial surgery

86 = Neuropsychiatry

87 = All other suppliers (e.g., drug

stores)

88 = Unknown provider

89 = Certified clinical nurse specialist

90 = Medical oncology

91 = Surgical oncology

92 = Radiation oncology

93 = Emergency medicine

94 = Interventional radiology

95 = Competitive Acquisition Program

(CAP) Vendor (eff. 07/2001/2006).

Prior to 07/2001/2006, known as

Independent physiological

laboratory

96 = Optician

97 = Physician assistant

98 = Gynecological/oncology

99 = Unknown physician specialty

A0 = Hospital (DMERCs only)

A1 = Skilled nursing facility (DMERCs

only)

A2 = Intermediate care nursing facility

(DMERCs only)

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A3 = Nursing facility, other (DMERCs

only)

A4 = Home health agency (DMERCs

only)

A5 = Pharmacy (DMERC)

A6 = Medical supply company with

respiratory therapist (DMERCs

only)

A7 = Department store (DMERC)

A8 = Grocery store (DMERC)

A9 = Indian Health Service (IHS), tribe

and tribal organizations (non-

hospital or non-hospital-based

facilities, eff. 1/2005)

B1 = Supplier of oxygen and/or oxygen

related equipment (eff. 10/2007)

B2 = Pedorthic Personnel (eff.

10/2007)

B3 = Medical Supply Company with

pedorthic personnel (eff.

10/2007)

B4 = Does not meet definition of

health care provider (e.g.,

Rehabilitation agency, organ

procurement organizations,

histocompatibility labs) (eff.

10/2/2007)

B5 = Ocularist

C0 = Sleep medicine

C1 = Centralized flu

C2 = Indirect payment procedure

C3 = Interventional cardiology

C5 = Dentist (eff. 7/2016)

C6 = Hospitalist

C7 = Advanced heart failure and

transplant cardiology

C8 = Medical toxicology

C9 = Hematopoietic cell transplantation

and cellular therapy

D3 = Medical genetics and genomics

D4 = Undersea and Hyperbaric Medicine

D5 = Opioid Treatment Program (eff.

1/2020)

D7 = Micrographic Dermatologic Surgery

(MDS) (eff. 10/2020)

D8 = Adult Congenital Heart Disease

E1 = Marriage and Family Therapists

E2 = Mental Health Counselors

E3 = Dental Anesthesiology

E4 = Dental Public Health

E5 = Endodontics

E6 = Oral and Maxillofacial Pathology

E7 = Oral and Maxillofacial Radiology

E9 = Oral Medicine

F1 = Orofacial Pain

F2 = Orthodontics and Dentofacial Orthopedics

F3 = Pediatric Dentistry

F4 = Periodontics

F5 = Prosthodontics

COMMENT: This field appears on both the revenue center and base claim files.

^ Back to TOC ^

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RNDRNG_PHYSN_UPIN

LABEL: Revenue Center Rendering Physician UPIN

DESCRIPTION: This variable is the unique physician identification number (UPIN) for the physician who rendered the

services on the revenue center record.

NPIs replaced UPINs as the standard provider identifiers beginning in 2007. The UPIN is almost never

populated after 2009.

SHORT NAME: RNDRNG_PHYSN_UPIN

LONG NAME: RNDRNG_PHYSN_UPIN

TYPE: CHAR

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: —

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RNDRNG_PHYSN_UPIN

LABEL: Revenue Center Rendering Physician UPIN

DESCRIPTION: This variable is the unique physician identification number (UPIN) for the physician who rendered the

services on the revenue center record.

NPIs replaced UPINs as the standard provider identifiers beginning in 2007. The UPIN is almost never

populated after 2009.

SHORT NAME: RNDRNG_PHYSN_UPIN

LONG NAME: RNDRNG_PHYSN_UPIN

TYPE: CHAR

LENGTH: 12

SOURCE: NCH

VALUES: —

COMMENT: —

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RNDRNG_PRVDR_SPCLTY_CD1

RNDRNG_PRVDR_SPCLTY_CD2

RNDRNG_PRVDR_SPCLTY_CD3

LABEL: Rendering Provider Secondary Specialty Code (1–3)

DESCRIPTION: CMS secondary specialty code(s) for the rendering (aka performing) provider on the non-institutional

claim.

Applies to the PRF_PHYSN_NPI on the carrier line file. These rendering provider specialty codes are in

addition to the Line CMS Provider Specialty Code (PRVDR_SPCLTY).

SHORT NAME: RNDRNG_PRVDR_SPCLTY_CD1

RNDRNG_PRVDR_SPCLTY_CD2

RNDRNG_PRVDR_SPCLTY_CD3

LONG NAME: RNDRNG_PRVDR_SPCLTY_CD1

RNDRNG_PRVDR_SPCLTY_CD2

RNDRNG_PRVDR_SPCLTY_CD3

TYPE: CHAR

LENGTH: 2

SOURCE: NCH

VALUES:

00 = Carrier wide

01 = General practice

02 = General surgery

03 = Allergy/immunology

04 = Otolaryngology

05 = Anesthesiology

06 = Cardiology

07 = Dermatology

08 = Family practice

09 = Interventional Pain Management

(IPM) (eff. 4/2003)

10 = Gastroenterology

11 = Internal medicine

12 = Osteopathic manipulative therapy

13 = Neurology

14 = Neurosurgery

15 = Speech/language pathology

16 = Obstetrics/gynecology

17 = Hospice and Palliative Care

18 = Ophthalmology

19 = Oral surgery (dentists only)

20 = Orthopedic surgery

21 = Cardiac Electrophysiology

22 = Pathology

23 = Sports Medicine

24 = Plastic and reconstructive surgery

25 = Physical medicine and rehabilitation

26 = Psychiatry

27 = General Psychiatry

28 = Colorectal surgery (formerly

proctology)

29 = Pulmonary disease

30 = Diagnostic radiology

31 = Intensive cardiac rehabilitation

32 = Anesthesiologist Assistants (eff.

4/2003 — previously grouped

with Certified Registered Nurse

Anesthetists [CRNA])

33 = Thoracic surgery

34 = Urology

35 = Chiropractic

36 = Nuclear medicine

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37 = Pediatric medicine

38 = Geriatric medicine

39 = Nephrology

40 = Hand surgery

41 = Optometrist

42 = Certified nurse midwife

43 = Certified Registered Nurse

Anesthetist (CRNA)

(Anesthesiologist Assistants

were removed from this

specialty 4/1/2003)

44 = Infectious disease

45 = Mammography screening center

46 = Endocrinology

47 = Independent Diagnostic Testing

Facility (IDTF)

48 = Podiatry

49 = Ambulatory surgical center

(formerly miscellaneous)

50 = Nurse practitioner

51 = Medical supply company with

certified orthotist (certified by

American Board for Certification

in Prosthetics and Orthotics)

52 = Medical supply company with

certified prosthetist (certified by

American Board for Certification

in Prosthetics and Orthotics)

53 = Medical supply company with

certified prosthetist-orthotist

(certified by American Board for

Certification in Prosthetics and

Orthotics)

54 = Medical supply company for

DMERC (and not included in 51–

53)

55 = Individual certified orthotist

56 = Individual certified prosthetist

57 = Individual certified prosthetist-

orthotist

58 = Medical supply company with

registered pharmacist

59 = Ambulance service supplier, (e.g.,

private ambulance companies,

funeral homes, etc.)

60 = Public health or welfare agencies

(federal, state, and local)

61 = Voluntary health or charitable

agencies (e.g., National Cancer

Society, National Heart

Association, Catholic Charities)

62 = Psychologist (billing

independently)

63 = Portable X-ray supplier

64 = Audiologist (billing independently)

65 = Physical therapist (private practice

added 4/1/2003) (independently

practicing removed 4/1/2003)

66 = Rheumatology

67 = Occupational therapist (private

practice added 4/1/2003)

(independently practicing removed

4/1/2003)

68 = Clinical psychologist

69 = Clinical laboratory (billing

independently)

70 = Single or multispecialty clinic or

group practice

71 = Registered Dietician/Nutrition

Professional (eff. 1/1/2002)

72 = Pain Management (eff. 1/1/2002)

73 = Mass Immunization Roster Biller

74 = Radiation Therapy Centers (prior to

4/2003 this included Independent

Diagnostic Testing Facilities (IDTF)

75 = Slide Preparation Facilities (added

to differentiate them from

Independent Diagnostic Testing

Facilities (IDTFs — eff. 4/1/2003)

76 = Peripheral vascular disease

77 = Vascular surgery

78 = Cardiac surgery

79 = Addiction medicine

80 = Licensed clinical social worker

81 = Critical care (intensivists)

82 = Hematology

83 = Hematology/oncology

84 = Preventive medicine

85 = Maxillofacial surgery

86 = Neuropsychiatry

87 = All other suppliers (e.g., drug and

department stores)

88 = Unknown supplier/provider

specialty

89 = Certified clinical nurse specialist

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90 = Medical oncology

91 = Surgical oncology

92 = Radiation oncology

93 = Emergency medicine

94 = Interventional radiology

95 = Competitive Acquisition Program

(CAP) Vendor (eff.

07/2001/2006). Prior to

07/2001/2006, known as

Independent physiological

laboratory

96 = Optician

97 = Physician assistant

98 = Gynecologist/oncologist

99 = Unknown physician specialty

A0 = Hospital (DMERCs only)

A1 = SNF (DMERCs only)

A2 = Intermediate care nursing facility

(DMERCs only)

A3 = Nursing facility, other (DMERCs

only)

A4 = Home health agency (DMERCs

only)

A5 = Pharmacy (DMERC)

A6 = Medical supply company with

respiratory therapist (DMERCs

only)

A7 = Department store (DMERC)

A8 = Grocery store (DMERC)

A9 = Indian Health Service (IHS), tribe

and tribal organizations (non-

hospital or non-hospital-based

facilities, eff. 1/2005)

B1 = Supplier of oxygen and/or oxygen

related equipment (eff. 10/2007)

B2 = Pedorthic Personnel (eff.

10/2007)

B3 = Medical Supply Company with

pedorthic personnel (eff.

10/2007)

B4 = Does not meet definition of

health care provider (e.g.,

Rehabilitation agency, organ

procurement organizations,

histocompatibility labs) (eff.

10/2007)

B5 = Ocularist

C0 = Sleep medicine

C1 = Centralized flu

C2 = Indirect payment procedure

C3 = Interventional cardiology

C5 = Dentist

C6 = Hospitalist

C7 = Advanced Heart Failure and

Transplant Cardiology

C8 = Medical Toxicology

C9 = Hematopoietic Cell

Transplantation and Cellular

Therapy

D3 = Medical Genetics and Genomics

D4 = Undersea and Hyperbaric Medicine

D5 = Opioid Treatment Program (eff. 1/2020)

D7 = Micrographic Dermatologic Surgery

D8 = Adult Congenital Heart Disease

E1 = Marriage and Family Therapists

E2 = Mental Health Counselors

E3 = Dental Anesthesiology

E4 = Dental Public Health

E5 = Endodontics

E6 = Oral and Maxillofacial Pathology

E7 = Oral and Maxillofacial Radiology

E9 = Oral Medicine

F1 = Orofacial Pain

F2 = Orthodontics and Dentofacial Orthopedics

F3 = Pediatric Dentistry

F4 = Periodontics

F5 = Prosthodontic

COMMENT: These fields were added in October 2023.

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RNDRNG_PRVDR_TXNMY_CD

LABEL: Rendering Provider Taxonomy Code

DESCRIPTION: Rendering provider taxonomy code. Applies to the PRF_PHYSN_NPI on the carrier line file. A taxonomy

code is a unique 10-character code that assigns a provider's classification and specialization. Providers

use this code when applying for a National Provider Identifier (NPI).

SHORT NAME: RNDRNG_PRVDR_TXNMY_CD

LONG NAME: RNDRNG_PRVDR_TXNMY_CD

TYPE: CHAR

LENGTH: 10

SOURCE: NCH

VALUES: XXXXXXXXX

Null/missing

COMMENT: There are also rendering provider specialty code fields on the carrier line, including the line CMS

provider specialty code (PRVDR_SPCLTY) and three secondary specialty codes

(RNDRNG_PRVDR_SPCLTY_CD1–3).

This field was new in October 2023.

This code set is an external code set maintained by the National Uniform Claim Committee (NUCC)

(https://www.nucc.org/index.php).

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RR_BRD_EXCLSN_IND_SW

LABEL: Railroad Board Exclusion Indicator Switch

DESCRIPTION: This field indicates whether Railroad Board (RRB) beneficiary claim should be excluded from Prior

Authorization processing.

SHORT NAME: RR_BRD_EXCLSN_IND_SW

LONG NAME: RR_BRD_EXCLSN_IND_SW

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: Y = Yes (exclude RRB beneficiary from PA)

Null/missing = Subject RRB beneficiary services to prior authorization

COMMENT: This field informs the SSMs and CWF if the RRB beneficiary claim should either be included or excluded

from Prior Authorization (PA) processing. Ex: If the field is valued “Y”, and it is RRB beneficiary claim, it

will be excluded from PA processing.

This field was new in April 2019.

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RSN_VISIT_CD1

RSN_VISIT_CD2

RSN_VISIT_CD3

LABEL: Reason for Visit Diagnosis Code

DESCRIPTION: The diagnosis code used to identify the patient's reason for the hospital outpatient visit.

SHORT NAME: RSN_VISIT_CD1

RSN_VISIT_CD2

RSN_VISIT_CD3

LONG NAME: RSN_VISIT_CD1

RSN_VISIT_CD2

RSN_VISIT_CD3

TYPE: CHAR

LENGTH: 7

SOURCE: NCH

VALUES: —

COMMENT: Prior to version “J,” this field was: CLM_ADMTG_DGNS_CD.

With version “J,” the name has changed and there can be up to 3 occurrences of this group.

On October 1, 2015, the conversion from the 9th version of the International Classification of Diseases

(ICD-9-CM) to version 10 (ICD-10-CM) occurred.

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RSN_VISIT_VRSN_CD1

RSN_VISIT_VRSN_CD2

RSN_VISIT_VRSN_CD3

LABEL: Reason for Visit Diagnosis Code Version Code (ICD-9 or ICD-10)

DESCRIPTION: The code used to indicate if the reason for visit diagnosis code is ICD-9 or ICD-10.

SHORT NAME: RSN_VISIT_VRSN_CD1

RSN_VISIT_VRSN_CD1

LONG NAME: RSN_VISIT_VRSN_CD1

RSN_VISIT_VRSN_CD1

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: Blank = ICD-9

9 = ICD-9

0 = ICD-10

COMMENT: With 5010, the diagnosis and procedure codes expanded to accommodate ICD-10.

On October 1, 2015, the conversion from the 9th version of the International Classification of Diseases

(ICD-9-CM) to version 10 (ICD-10-CM) occurred.

This code is associated with the diagnosis code identified in the corresponding RSN_VISIT_CD#.

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SRVC_LOC_NPI_NUM

LABEL: Claim Service Location NPI Number

DESCRIPTION: The National Provider Identifier (NPI) of the location where the services were provided.

SHORT NAME: SRVC_LOC_NPI_NUM

LONG NAME: SRVC_LOC_NPI_NUM

TYPE: CHAR

LENGTH: 22

SOURCE: NCH

VALUES: —

COMMENT: This field was new in January 2014. It is null/missing for all years prior.

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TAX_NUM

LABEL: Line Provider Tax Number

DESCRIPTION: The federal taxpayer identification number (TIN) that identifies the physician/practice/supplier to

whom payment is made for the line-item service on the noninstitutional claim.

This number may be an employer identification number (EIN) or social security number (SSN).

SHORT NAME: TAX_NUM

LONG NAME: TAX_NUM

TYPE: CHAR

LENGTH: 10

SOURCE: NCH

VALUES: —

COMMENT: For DME claims, all 10 digits are populated. The first 9 digits represent the EIN or SSN, and the final

(rightmost) tenth digit indicates the type of provider ID that is used (reference the

DMERC_LINE_SUPPLR_TYPE_CD for these values). For all other claim types, only 9 digits of the field

are populated.

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THRPY_CAP_IND_CD1

THRPY_CAP_IND_CD2

THRPY_CAP_IND_CD3

THRPY_CAP_IND_CD4

THRPY_CAP_IND_CD5

LABEL: Therapy Cap Indicator Code

DESCRIPTION: The field used to identify whether the claim line (or revenue center) is subject to a therapy cap.

SHORT NAME: THRPY_CAP_IND_CD1

THRPY_CAP_IND_CD2

THRPY_CAP_IND_CD3

THRPY_CAP_IND_CD4

THRPY_CAP_IND_CD5

LONG NAME: THRPY_CAP_IND_CD1

THRPY_CAP_IND_CD2

THRPY_CAP_IND_CD3

THRPY_CAP_IND_CD4

THRPY_CAP_IND_CD5

TYPE: CHAR

LENGTH: 1

SOURCE: NCH

VALUES: A = Hospital outpatient claims are subject to the therapy cap for this date of service (this indicator is

used on institutional claims only).

B = Critical Access Hospital outpatient claims are subject to the therapy cap for this date of service

(this indicator will be used on institutional claims only). NOTE: Currently, Critical Access Hospital

claims are not subject to any therapy cap policies. Indicator B is created here to prepare for

possible future legislation to include these claims.

C = The therapy cap exceptions process, as indicated by the submission of the KX modifier, no longer

applies for this date of service (this indicator will be used on both institutional and professional

claims).

D = The $3,700 threshold for review therapy services no longer applies for this date of service (this

indicator will be used on both institutional and professional claims).

COMMENT: This field appears on the revenue center / line files.

In the carrier line file, there are up to five indicators for the therapy cap — reference variables called

THRPY_CAP_IND_CD1–THRPY_CAP_IND_CD5. In institutional revenue center files (inpatient, SNF,

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hospice, home health, and outpatient), there are two occurrences of this field (THRPY_CAP_IND_CD1–

THRPY_CAP_IND_CD2).

Details regarding the therapy cap can be found on the CMS website, under the Medicare therapy

services web page (reference, for example:

https://www.cms.gov/Medicare/Billing/TherapyServices/index.html).

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TRNSTNL_DRUG_ADD_ON_PYMT_AMT

LABEL: Transitional Drug Add-On Payment Amount

DESCRIPTION: This field houses the amount for the Transitional Drug Add-On Payment Adjustment (TDAPA) for ESRD

claims (72X) with injectable, intravenous, and oral calcimimetics when reported with an AX modifier.

These services qualify for an add-on payment from the ESRD Pricer.

SHORT NAME: TRNSTNL_DRUG_ADD_ON_PYMT_AMT

LONG NAME: TRNSTNL_DRUG_ADD_ON_PYMT_AMT

TYPE: NUM

LENGTH: 12

SOURCE: NCH

VALUES: XXX.XX

COMMENT: This field is new in 2018 and applies only to hospital outpatient claims.

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Chronic Conditions Warehouse Virtual Research Data Center CODEBOOK: Medicare Fee-For-Service (FFS) Claims (version L) PDF Free Download

Chronic Conditions Warehouse Virtual Research Data Center CODEBOOK: Medicare Fee-For-Service (FFS) Claims (version L) PDF free Download. Think more deeply and widely.

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